medical protocols, procedures and treatment guidelines

PLATTEVILLE GILCREST FIRE PROTECTION DISTRICT

MEDICAL PROTOCOLS, PROCEDURES AND TREATMENT GUIDELINES

REVISION FEBRUARY 2020

PGFPD Protocol DevelopmentRandy Benish, NR-PMatt Concialdi, M.S., NR-P

Kristen Knowles, D.O.

Ben Krapes, NR-EMTLiz Lopez, NR-PDave Sutton, NR-PNathaniel Klimek, PEdited by Vanessa Wader

The process that has been initiated in the construction of the protocols will remain in place until the next protocol revision. The authors will continue to edit and revise the protocols to reflect the dynamic role of emergency medical services within the medical care community.

The developers of the protocols would like to acknowledge the following for their contribution, talent and time in this edition of the PGFPD Protocols:

Denver Metro EMS Medical Directors Kathleen Adelgais, M.D. Jonathan Apfelbaum, M.D. Jeff Beckman, M.D. JP Brewer, M.D. Daniel Cheek, M.D. Eugene Eby, M.D. Eric Hill, M.D. Michael Hunt, M.D. Dylan Luyten, M.D. Maria Mandt, M.D. Kevin McVaney, M.D. Tom Paluska, M.D. Gilbert Pineda, M.D. Lara Rappaport, M.D. John Riccio, M.D. David Richter, M.D. Jason Roosa, M.D. Fred Severyn, M.D. Gina Soriya, M.D. W. Peter Vellman, M.D.Gary Witt, M.D.Participating Denver Metro Agencies

Weld County EMS Protocol Group Joshua Poles, D.O.Jeff Stranahan, Paramedic Participating Weld County Agencies

Table of Contents

General Guidelines (0001-0999)

• 0010 Introduction

• 0020 Confidentiality

• 0030 Consent

• 0040 Physician at the Scene/Medical Direction

• 0050 Field Pronouncement

• 0051 Termination of Resuscitation• 0060 Advanced Medical Directives

• 0070 Patient Determination: “Patient or No Patient”• 0080 Patient Non-Transport or Refusal

• 0090 Emergency Department Divert and Advisory

• 0100 Mandatory Reporting of Abuse Patients

• 0110 Free-Standing Emergency Departments as EMS Destination

• 0120 Base Contact for Physician Consultation

• 0130 Transportation of the Pediatric Patient

• 0140 Cancellation Policy• 0150 Radio Report Format Policy• 0990 Quick Reference for Procedures and Medications Allowed by Protocol

Procedures (1000-1250)• 1000 Intubation: Oral

• 1010 Intubation: Nasal

• 1030 Bougie Assisted Surgical Cricothyrotomy

• 1040 Pediatric Needle Cricothyrotomy

• 1050 Supraglottic Airway

• 1060 Continuous Positive Airway Pressure (CPAP)

• 1070 Capnography

• 1080 Needle Thoracostomy for Tension Pneumothorax Decompression

• 1090 Synchronized Cardioversion

• 1100 Transcutaneous Cardiac Pacing

• 1110 Intraosseous Catheter Placement

• 1120 Tourniquet Protocol

• 1130 Restraint Protocol

• 1140 Orogastric Tube Insertion with Advanced Airway

• 1150 TASER® Probe Removal• 1160 Cardiac Monitor - 4 lead EKG

• 1170 Cardiac Monitor -12 lead EKG

• 1190 Pulse Oximeter Monitoring

• 1200 Splinting - Extremity

• 1210 Suctioning - Endotracheal

• 1220 Suctioning - Phayngeal

• 1230 Pain Management

• 1240 Sam Pelvic Sling

• 1250 Patella Relocation

•

• 118

Cardiac Protocols (3000-3999)

• 3000 Universal Pulseless Arrest• 3010 Universal Pulseless Arrest Considerations• 3020 Neonatal Resuscitation• 3030 Post-Resuscitation Care with ROSC• 3040 Tachyarrhythmia with Poor Perfusion• 3050 Bradyarrhythmia with Poor Perfusion• 3060 Chest Pain• 3070 Cardiac Alert• 3080 Hypertension• 3090 Ventricular Assist Devices (VAD)

General Medical Protocols (4000-4999)

• 4000 Medical Shock• 4010 Universal Altered Mental Status• 4020 Syncope• 4030 Stroke• 4040 Seizure• 4050 Hypoglycemia• 4060 Pediatric BRUE (Formerly ALTE)• 4070 Drug/Alcohol Intoxication• 4080 Overdose and Acute Poisoning• 4090 Allergy and Anaphylaxis• 4100 Non-Traumatic Abdominal Pain/Vomiting• 4110 Suspected Carbon Monoxide Exposure• 4120 Adrenal Insufficiency• 4130 Epistaxis Management• 4140 Sepsis Criteria

• 2000 Obstructed Airway• 2010 Adult Universal Respiratory Distress• 2020 Pediatric Universal Respiratory Distress• 2030 Adult Wheezing• 2040 Pediatric Wheezing• 2050 Pediatric Stridor/Croup

• 2060 CHF/Pulmonary Edema

Respiratory Protocols (2000-2999)

Environmental Protocols (5000-4999)

• 5000 Drowning

• 5010 Hypothermia

• 5020 Hyperthermia

• 5030 Altitude Illness

• 5040 Insect/Arachnid Stings and Bites

• 5050 Snake Bite

Behavioral Protocols (6000-6999)

• 6000 Psychiatric/Behavioral Patient

• 6010 Agitated/Combative Patient

• 6020 Transport of the Handcuffed Patient

Obstetric Protocols (7000-7999)

• 7000 Childbirth

• 7010 Obstetrical Complications

Trauma Protocols (8000-8999)

• 8000 General Trauma Care

• 8010 Special Trauma Scenarios: Sexual Assault and Abuse/Neglect

• 8020 Trauma in Pregnancy

• 8030 Traumatic Pulseless Arrest

• 8040 Traumatic Shock

• 8050 Amputations

• 8055 Crush Injuries• 8060 Head Trauma

• 8070 Face and Neck Trauma

• 8080 Spinal Trauma

• 8090 Spinal Precautions

• 8100 Suspected Spinal Injury with Protective Athletic Equipment in Place

• 8110 Chest Trauma

• 8120 Abdominal Trauma

• 8130 Burns

• 8150 Trauma Team Activation• 8160 Triage Destination Protocol

Medication Protocols (9000-9999)

• 9000 Medication Administration Guidelines

• 9005 Medications- Acetaminophen• 9010 Adenosine

• 9020 Albuterol Sulfate

• 9030 Amiodarone

• 9040 Antiemetics

• 9050 Aspirin

• 9060 Atropine Sulfate

• 9070 Benzodiazepines (IV)• 9075 Benzodiazepines (Oral)• 9080 Calcium

• 9090 Dextrose

• 9100 Diphenhydramine

• 9115 DuoDote™• 9120 Epinephrine

• 9130 Glucagon

• 9140 Haloperidol

• 9150 Hemostatic Agents

• 9160 Hydroxocobalamin

• 9165 Ibuprofen• 9170 Ipatropium Bromide

• 9175 Ketamine• 9180 Lidocaine 2%

• 9190 Magnesium Sulfate

• 9200 Methylprednisolone

• 9210 Naloxone

• 9220 Nitroglycerin

• 9230 Opioids

• 9240 Oral Glucose

• 9250 Oxygen

• 9260 Phenylephrine

• 9270 Racemic Epinephrine

• 9280 Sodium Bicarbonate

• 9290 Topical Ophthalmic Anesthetics

• 9300 Vasopressor Continuous Infusion – Adult Patients Only

Appendix A - Pit Crew CPR

Appendix B - Checklists- Stroke, Cardiac Alert, Sepsis

Appendix C - Triage Algorithm

Appendix D - Highly Infectious Disease

Appendix E - Approved Abbreviations

0010 GENERAL GUIDELINES: INTRODUCTION

INTRODUCTION

The following protocols have been developed and approved by the Platteville Gilcrest Fire Protection District (PGFPD) Medical Director. These protocols define the standard of care forEMS providers in the Platteville Gilcrest area, and delineate the expected practice, actions, andprocedures to be followed.

No protocol can account for every clinical scenario encountered, and the PGFPD recognize that in rare circumstances deviation from these protocols may be necessary and in a patient’s best interest. Variance from protocol should always be done with the patient’s best interest in mind and backed by documented clinical reasoning and judgment. Whenever possible, prior approval by direct verbal order from base station physician is preferred. Additionally, all variance from protocol should be documented and submitted for review by the agency’s Medical Director in a timely fashion.

The protocols are presented in an algorithm format. An algorithm is intended to reflect real-life decision points visually. An algorithm has certain limitations, and not every clinical scenario can be represented. Although the algorithm implies a specific sequence of actions, it may often be necessary to provide care out of sequence from that described in the algorithm if dictated by clinical needs. An algorithm provides decision-making support, but need not be rigidly adhered to and is no substitute for sound clinical judgment.

In order to keep protocols as uncluttered as possible, and to limit inconsistencies, individual drug dosing has not been included in the algorithms. It is expected the EMTs will be familiar with standard drug doses. Drug dosages are included with the medications section of the protocols as a reference.

If viewing protocol in an electronic version, it will be possible to link directly to a referenced protocol by clicking on the hyperlink, which is underlined.

PROTOCOL KEY

Boxes without any color fill describe actions applicable to all certification levels. Boxes with orange fill are for actions for intermediate level or higher, and blue-filled boxes are for Paramedic level. When applicable, actions requiring Base Contact are identified in the protocol.

Teaching points deemed sufficiently important to be included in the protocol are separated into grey-filled boxes with a double line border.

PROTOCOLS CONSIDERATIONS SPECIFIC TO AGE

For the purposes of these clinical care protocols, pediatric patients are those less than 12 years of age. Infant is defined as less than 1 year of age. Neonate is defined as less than one month of age. Pediatric specific indications will be noted by a purple box. Geriatric patients will be considered greater than 65 years of age. Geriatric specific indications will be indicated by a green box.

TRAINING AND EDUCATION

These protocols define the treatments, procedures, and policies approved by the PGFPD Medical Director. In Colorado, the scope of practice and acts allowed for EMT, EMT-IV, AEMT, EMT-I andParamedic certifications are defined by the Colorado Department of Public Health and Environment, Chapter Two - Rules Pertaining to EMS Practice and Medical Director Oversight. These protocols do not supersede Chapter Two allowances, but in some instances may vary from Chapter Two depending on medical directors’ preference.

The curriculum for initial EMS provider training may not cover some of the treatments, procedures and medications included in these protocols. Therefore, it is the responsibility of the EMS agency and Medical Director to ensure the initial training, verification, and maintenance of these skills falling outside traditional EMS education with all agency providers. This may be of additional importance when training and orienting newly hired providers prior to independent practice.

Approved by Platteville Gilcrest FPD Medical Director January 1, 2019

EMT AEMT

Intermediate Paramedic

• Teaching points

Pediatric Protocol

Geriatric Protocol

0020 GENERAL GUIDELINES: CONFIDENTIALITY

Approved by the Platteville-Gilcrest FPD Medical Director August, 2019

CONFIDENTIALITY A. The patient-physician relationship, the patient-registered nurse relationship, and the patient-EMT

relationship are recognized as privileged. This means that the physician, nurse, or EMT may nottestify as to confidential communications unless:

1. The patient consents

2. The disclosure is allowable by law (such as Medical Board or Nursing Board proceedings,or criminal or civil litigation in which the patient's medical condition is in issue)

B. The prehospital provider must keep the patient's medical information confidential. The patient likelyhas an expectation of privacy, and trusts that personal, medical information will not be disclosedby medical personnel to any person not directly involved in the patient's medical treatment.

1. Exceptions

i. The patient is not entitled to confidentiality of information that does not pertain tothe medical treatment, medical condition, or is unnecessary for diagnosis ortreatment.

ii. The patient is not entitled to confidentiality for disclosures made publicly.

iii. The patient is not entitled to confidentiality with regard to evidence of a crime.

C. Additional Considerations:

1. Any disclosure of medical information should not be made unless necessary for thetreatment, evaluation or diagnosis of the patient.

2. Any disclosures made by any person, medical personnel, the patient, or law enforcementshould be treated as limited disclosures and not authorizing further disclosures to any otherperson.

3. Any discussions of prehospital care by and between the receiving hospital, thecrewmembers in attendance, or at in-services or audits which are done strictly foreducational or performance improvement purposes, will fall under the “Carol J.Shanaberger Act” Colorado Revised Statutes §25-3.5-901 et seq., provided that allappropriate criteria have been met for the agencies peer protection program. Furtherdisclosures are not authorized.

4. Radio communications should not include disclosure of patient names.

5. This procedure does not preclude or supersede your agency’s HIPAA policy andprocedures.

6. Any communication from the prehospital setting to the receiving hospital or other facility orcare provider should be kept in compliance with HIPAA including all smart technology,SMS messaging, wireless communication or otherwise. No personal identifier informationshould be transmitted over non-HIPAA compliant secure means.

https://advance.lexis.com/api/document/collection/statutes-legislation/id/5PC1-8490-004D-137S-00008-00?cite=C.R.S.%2025-3.5-901&context=1000516

0030 GENERAL GUIDELINES: CONSENT

Approved by Platteville Gilcrest FPD Medical Director January 1, 2019.

General Principles: Adults

A. An adult in the State of Colorado is 18 years of age or older.B. Every adult is presumed capable of making medical treatment decisions. This includes the right to make "bad"

decisions that the prehospital provider believes are not in the best interests of the patient.C. A person is deemed to have decision-making capacity if he/she has the ability to provide informed consent, i.e.,

the patient:1. Understands the nature of the illness/injury or risk of injury/illness.2. Understands the possible consequences of delaying treatment and/or refusing transport.3. Not intoxicated with drugs and/or alcohol4. Given the risks and options, the patient voluntarily refuses or accepts treatment and/or transport.

D. A call to 9-1-1 itself does not prevent a patient from refusing treatment. A patient may refuse medical treatment(IVs, oxygen, medications), but you should try to inform the patient of the need for therapies, offer again, andtreat to the extent possible.

E. The odor of alcohol on a patient’s breath does not, by itself, prevent a patient from refusing treatment.F. Implied Consent: An unconscious adult is presumed to consent to treatment for life-threatening

injuries/illnesses.G. Involuntary Consent: a person other than the patient in rare circumstances may authorize Consent. This may

include a court order (guardianship), authorization by a law enforcement officer for prisoners in custody ordetention, or for persons under a mental health hold or commitment who are a danger to themselves or othersor are gravely disabled.

Procedure: Adults

A. Consent may be inferred by the patient's actions or by express statements. If you are not sure that you haveconsent, clarify with the patient or CONTACT BASE. This may include consent for treatment decisions ortransport/destination decisions.

B. Determining whether or not a patient has decision-making capacity to consent or refuse medical treatment inthe prehospital setting can be very difficult. Every effort should be made to determine if the patient hasdecision-making capacity, as defined above.

C. For patients who do not have decision-making capacity, CONTACT BASE.D. If the patient lacks decision-making capacity and the patient's life or health is in danger, and there is no

reasonable ability to obtain the patient's consent, proceed with transport and treatment of life-threateninginjuries/illnesses. If you are not sure how to proceed, CONTACT BASE.

E. For patients who refuse medical treatment, if you are unsure whether or not a situation of involuntary consentapplies, CONTACT BASE.

General Principles: Minors

A. A parent, including a parent who is a minor, may consent to medical or emergency treatment of his/her child.There are exceptions:

1. Neither the child nor the parent may refuse medical treatment on religious grounds if the child is inimminent danger as a result of not receiving medical treatment, or when the child is in a life-threatening situation, or when the condition will result in serious handicap or disability.

2. The consent of a parent is not necessary to authorize hospital or emergency health care when an EMTin good faith relies on a minor's consent, if the minor is at least 15 years of age and emancipated ormarried.

3. Minors may seek treatment for abortion, drug addiction, and venereal disease without consent ofparents. Minors > 15 years may seek treatment for mental health.

B. When in doubt, your actions should be guided by what is in the minor's best interests and base contact.

Procedure: Minors

A. A parent or legal guardian may provide consent to or refuse treatment in a non- life-threatening situation.B. When the parent is not present to consent or refuse:

1. If a minor has an injury or illness, but not a life-threatening medical emergency, you should attempt tocontact the parent(s) or legal guardian. If this cannot be done promptly, transport.

2. If the child does not need transport, they can be left at the scene in the custody of a responsible adult(e.g., teacher, social worker, grandparent). It should only be in very rare circumstances that a child ofany age is left at the scene if the parent is not also present.

3. If the minor has a life-threatening injury or illness, transport and treat per protocols. If the parentobjects to treatment, CONTACT BASE immediately and treat to the extent allowable, and notify policeto respond and assist.

0040 GENERAL GUIDELINES: PHYSICIAN AT THE SCENE/MEDICAL DIRECTION

Purpose

A. To provide guidelines for prehospital personnel who encounter a physician at the scene of anemergency

General Principles

A. The prehospital provider has a duty to respond to an emergency, initiate treatment, and conductan assessment of the patient to the extent possible.

B. A physician who voluntarily offers or renders medical assistance at an emergency scene isgenerally considered a "Good Samaritan." However, once a physician initiates treatment, he/shemay feel a physician-patient relationship has been established.

C. Good patient care should be the focus of any interaction between prehospital care providers andthe physician.

Procedure

A. See algorithm below and sample note to physician at the scene

Special notes

A. Every situation may be different, based on the physician, the scene, and the condition of thepatient.

B. CONTACT BASE when any question(s) arise.



NOTE TO PHYSICIANS ON INVOLVEMENT WITH EMS PROVIDERS

THANK YOU FOR OFFERING YOUR ASSISTANCE.

The prehospital personnel at the scene of this emergency operate under standard policies, procedures, and protocols developed by their Medical Director. The drugs carried and procedures allowed are restricted by law and written protocols. After identifying yourself by name as a physician licensed in the State of Colorado and providing identification, you may be asked to assist in one of the following ways:

1. Offer your assistance or suggestions, but the prehospital care providers willremain under the medical control of their base physician, or

2. With the assistance of the prehospital care providers, talk directly to the basephysician and offer to direct patient care and accompany the patient to thereceiving hospital. Prehospital care providers are required to obtain an orderdirectly from the base physician for this to occur.

THANK YOU FOR OFFERING YOUR ASSISTANCE DURING THIS EMERGENCY.

Medical Director Agency



PHYSICIAN AT THE SCENE/MEDICAL DIRECTION ALGORITHM

EMT attempts patient care

EMS arrives on scene

Physician reports on patient and relinquishes patient care

Provide care per protocol

Physician wants to help or is involved in or will not relinquish patient care

Prehospital provider identifies self and level of training

Physician willing to just help out

Provide general instructions and utilize physician assistance

Physician requests or performs care inappropriate or inconsistent with protocols

Shares Physician at the Scene/Medical Direction Note with physician and advise physician of your

responsibility to the patient

Physician does not relinquish patient care

and continues with care inconsistent with

protocols

CONTACT BASE for Medical Consult

Physician complies

Provide care per protocol

0050 GENERAL GUIDELINES: FIELD PRONOUNCEMENT

Approved by Platteville-Gilcrest FPD Medical Director August, 2019

Purpose A. To provide guidelines for resuscitation and field pronouncement of patients in cardiac arrest in the

prehospital setting. EMS may transport any patient perceived to be viable, or if scene dynamics orpublic perception necessitates transport.

General Principles A. Agency policy determines base contact requirements for patients for whom resuscitation efforts are

being withheld.B. Medical Arrest:

1. EMS providers should try their best to determine a patient’s end-of-life wishes and honorthem. Refer to Advanced Medical Directives protocol for discussion of advanced directivesand decision making about appropriateness of performing or withholding resuscitation efforts.

a. Do not attempt resuscitation for patients with a “No CPR” directive based on thepatient’s wishes or compelling reasons to withhold resuscitation as covered in AdvancedMedical Directives protocol.

b. Do not attempt resuscitation for patients with definite signs of death, such as dependentlividity, rigor mortis, decomposition.

C. Traumatic Arrest:1. Do not attempt resuscitation if there is evidence of a non-survivable injury and no sign of life.

Examples of non-survivable injuries include decapitation, evidence of massive head, chest, orabdominal trauma, or massive burn with charring.

2. Blunt trauma: consider field pronouncement if there are no signs of life. Signs of life includespontaneous movement, breathing, presence of a pulse, or reactive pupils.

3. Penetrating trauma: consider field pronouncement if there are no signs of life, and the arrestduration is suspected to be > 10 minutes.

4. Exceptions to the above recommendations to consider field pronouncement include arrestswith the following mechanisms/scenarios:

a. Hypothermic arrestb. Drowning w/ hypothermia and submersion < 60 minc. Lightning strike and electrocutiond. Avalanche victime. Pregnant patient with estimated gestational age ≥20 weeks

0051 GENERAL GUIDELINES: TERMINATION OF RESUSCIATION FOR MEDICAL PULSELESS ARREST

Purpose A. To provide guidelines for termination of resuscitation (TOR) for patients in medical pulseless arrest

in the prehospital setting. EMS may transport any patient perceived to be viable, or if scenedynamics or public perception necessitates transport.

General Principles A. Resuscitate according to Universal Pulseless Arrest Algorithm on scene (unless unsafe) until one of

the following endpoints is met:1. Return of spontaneous circulation (ROSC).2. No ROSC despite 30 minutes of ALS care or BLS care with an AED. If shockable rhythm still

present, continue resuscitation and transport to closest emergency department.3. Contact base for TOR at any point if the effort is considered futile despite adequate CPR with

ventilation and no reversible causes have been identified.B. For BLS-only providers, contact base for TOR when all of the following criteria met:

1. No AED shock advised2. No ROSC3. Arrest unwitnessed by either EMS or bystanders4. No bystander CPR before EMS arrival

C. The following patients found pulseless and apneic warrant resuscitation efforts beyond 30 minutesand should be transported:

1. Hypothermic arrest2. Drowning w/ hypothermia and submersion < 60 min3. Lightning strike and electrocution4. Avalanche victim5. Pregnant patient with estimated gestational age ≥20 weeks

D. Once the patient is pronounced, they become a potential coroner’s case. From that point on thepatient should not be moved and no clothing or medical devices (lines, tubes etc.) should beremoved or altered pending coroner evaluation.

Approved by Platteville Gilcrest FPD Medical Director August, 2019

0060 General Guidelines: Advanced Medical Directives


General Principles:

1. These guidelines apply to both adult and pediatric patients.2. It is the intention of this guideline to protect the welfare of patients and to respect the

appropriate exercise of professional judgments made in good faith by EMS personnel. Incases where there is doubt, contact base physician for consult.

3. From Colorado State Statute: Any EMS personnel who in good faith complies with a CPRdirective shall not be subject to civil or criminal liability or regulatory sanction for suchcompliance pursuant to CRS Section 15-18.6-104

4. EMS providers should try their best to determine a patient’s end-of-life wishes and honorthem. These wishes may not be written down or documentation may be unavailable. Incases where no documentation exists, consider if compelling reasons to withholdresuscitation exist. Example of compelling reasons to withhold resuscitation may includewhen written information is not available, yet the situation suggests that the resuscitationeffort will be futile, inappropriate, and inhumane and the family, life partner, caregiver, orhealthcare agent indicates that the patient would not wish to be resuscitated.

5. Specific examples where resuscitation efforts should be withheld or stopped include:a. A readily available “No CPR” directive based on the patient’s wishes:

i. According to CO State Rules this could include: personally written directive,wallet card, “No CPR” bracelet, Healthcare Agent verbal request, MOSTform, or other document or item of information that directs that resuscitationnot be attempted. Photocopied, scanned, faxed copies are valid.

b. The resuscitation may be stopped if after a resuscitation effort has been initiated, theEMS practitioner is provided with a Do Not Resuscitate directive or compellingreasons that such an effort should have been withheld.

c. Suspected suicide does not necessarily invalidate an otherwise valid No CPRdirective, DNR order, etc. When in doubt, contact base.

6. “Do Not Resuscitate” does not mean “do not care.” A dying patient for whom noresuscitation effort is indicated should still be provided with comfort care which may includethe following:

a. Clearing the airway (including stoma) of secretions.b. Provide oxygen using nasal cannula or facemask and other non-invasive measures

to alleviate respiratory distress.c. Pain management.d. Transport to the hospital as needed to manage symptoms with the No CPR directive

in place

Additional Considerations

1. Document the presence of the CPR Directive on the incident report. Describe the patient’smedical history, presence of an advanced directive (if any), or verbal request to withholdresuscitation.

2. Mass casualty incidents are not covered in detail by these guidelines. (See State TraumaTriage Algorithm).

3. If the situation appears to be a potential crime scene, EMS providers should disturb thescene as little as possible and communicate with law enforcement regarding any items thatare moved or removed from the scene.

4. Mechanisms for disposition of bodies by means other than EMS providers and vehiclesshould be prospectively established in each county or locale.

5. In all cases of unattended deaths occurring outside of a medical facility, the coroner shouldbe contacted immediately.

0070 GENERAL GUIDELINES: PATIENT DETERMINATION: “PATIENT OR NO PATIENT”

Approved by Platteville Gilcrest FPD Medical Director January 2020

Person has a complaint

resulting in a call for help

Person lacks decision-making

capacity (See adjacent)

Person is a minor

(Age < 18 yrs)

Acute illness or injury suspected

based on appearance,

MOI, etc

3rd party caller indicates

individual is ill, injured or gravely

disabled*

No

Yes

No

No

No

Yes

Yes

Yes

Yes

No

General Guidelines This protocol is intended to refer to individual patient

contacts. In the event of a multiple party incident, such as a multi-vehicle collision, it is expected that a

reasonable effort will be made to identify those parties with acute illness or injuries. Adult patients indicating

that they do not wish assistance for themselves or dependent minors in such a multiple party incident do

not necessarily require documentation as patients.

No protocol can anticipate every scenario and providers must use best judgment. When in doubt as to whether individual is a “patient”, err on the

side of caution and perform a full assessment and documentation

Decision-Making Capacity (Must meet all criteria)

Understands nature of illness or injuryUnderstands consequences of refusal of careNot intoxicated with drugs or alcoholNo criteria for a Mental Health Hold:o Not homicidal or suicidalo Not gravely disabled or psychotico Not a danger to self or others

Individual meets definition of a

Patient (PCR Required)

Person does not meet definition of a patient, and does not require

PCR or refusal of care

*Reliable 3rd party caller.

0070a. - Assessment Algorithm

SCENE SIZE UP AND ASSESSMENT

Provide personal safety. Move patient if possible

without endangering EMS

SAFE FOR EMS, PATIENTS, AND BYSTANDERS UNSAFE

Evaluate Resources Needed

Initial Assessment

General impression of environment and chief complaint(level of consciousness, airway, breathing, and circulation)

IDENTIFY PRIORITY PATIENTS

STABLE UNSTABLE

• Conscious• Airway secure• Breathing adequate• Circulation ensured

• Unconscious Spinal Motion Restriction if trauma suspected • Airway compromised Secure and stabilize • Breathing absent or abnormal Begin Ventilation • Circulation Compromised Stabilize and resuscitate

Focused History and Physical Exam

Ongoing Assessment and Transport

Medical Trauma

Initiate care as appropriate

Detailed Physical

Exam

Ongoing Assessment

Rapidly Stabilize and Transport

Ongoing Assessment

Transport

Baseline Vital Signs • Level of Consciousness

o AVPUo GCS

• Blood Pressureo Patients 1 yr or

older shouldhave one auscultated BP

• Pulse• Respiratory Rate and

Effort• Skin Presentation

Secondary Vital Signs • Pulse Oximetry• Blood Glucose• Capnography

Approved by Platteville Gilcrest FPD Medical Director January 1, 2019..

0080 GENERAL GUIDELINES: PATIENT NON-TRANSPORT OR REFUSAL


EMS

Dispatch

Cancelled

PTA

Arrived on

scene

Not a patient

(see Patient

Determination)

Patient

Transport No

transport

Determine if

Standing Order

Refusal (SOR)

Standing Order Refusal

No Base Contact required

if ALL criteria met:

• 18 and older, or 5 andolder if parent/guardianon scene

• Patient has decision-making capacity

Base Contact

Required

• < 5 years old

• < 18 years old unlessparent/guardian onscene

• If uncertain aboutpatient’s decision-making capacity

A person who has decision-making capacity may

refuse examination, treatment and transport

Refer to General Guidelines: Consent for complete decision-making capacity guidelines

A person is deemed to have decision-making capacity if he/she has the ability to provide informed consent, i.e., the patient:

1. Understands the nature of the illness/injury orrisk of injury/illness

2. Understands the possible consequences ofdelaying treatment and/or refusing transport

3. Given the risks and options, the patientvoluntarily refuses or accepts treatment and/ortransport.

If in doubt about patient decision-making capacity,

CONTACT BASE for physician consult.

For potentially intoxicated patients, refer to

Drug/Alcohol Intoxication

High Risk Patients

Base contact is strongly recommended whenever, in the clinical judgement of the EMS provider, the patient is at high

risk of deterioration without medical intervention.

Documentation Requirements for Refusal

• Confirm decision-making capacity

• EMS assistance offered and declined

• Risks of refusal explained to patient

• Patient understands risks of refusal

• Name of Base Station physician authorizingrefusal of care unless standing order refusal

• Signed refusal of care against medical advicedocument, if possible

• Any minor with any complaint/injury is a patientand requires a PCR

0090 GENERAL GUIDELINES: EMERGENCY DEPARTMENT DIVERT AND ADVISORY


Purpose

A. To provide a standard approach to ambulance diversion that is practical for field useB. To facilitate unobstructed access to hospital emergency departments for ambulance patientsC. To allow for optimal destination policies in keeping with general EMS principles and Colorado

State Trauma System Rules and Regulations

General Principles

A. EMSystem, an internet-based tracking system, is used to manage hospital diversion state-wide.B. The State Trauma Triage Algorithms should be followedC. The only time an ambulance can be diverted from a hospital is when that hospital is posted on

EMSystem as being on official divert (RED) status.D. Overriding factors: the following are appropriate reasons for a Paramedic to override ED Divert

and, therefore, deliver a patient to an emergency department that is on ED divert:1. Cardiopulmonary arrest2. Imminent cardiopulmonary arrest3. Unmanageable airway emergencies4. Unstable trauma and burn patients transported to Level I and Level II Trauma Centers5. Patients meeting “Cardiac Alert“ criteria (participating hospitals)6. Patients meeting “Stroke Alert“ criteria (participating hospitals)7. Imminent delivery

E. Prehospital personnel should honor advisory categories, when possible, considering patient’scondition, travel time, and weather. Patients with specific problems that fall under an advisorycategory should be transported to a hospital not on that specific advisory when feasible.

F. There are several categories that are considered advisory (yellow) alert categories. Thesecategories are informational only and should alert field personnel that a hospital listed as being onan advisory alert may not be able to optimally care for a patient that falls under that advisorycategory.

G. The following are advisory (yellow) categories recognized by the State. Individual facilities maynot utilize these categories often, or ever:

1. ICU (Intensive Care Unit)2. Psych (Psychiatric)

H. Zone saturation exists when all hospitals within that zone are on ED Divert.I. A Zone Master is the designated hospital within a Zone responsible for determining and tracking

hospital assignments when the zone is saturated.J. When an ambulance is transporting a patient that the Paramedic feels cannot go outside the zone

due to patient acuity or other concerns, the Paramedic should contact the Zone Master andrequest a destination assignment.

K. In general, patients contacted within a zone should be transported to an appropriate facility withinthe zone. Patients may be transported out of the primary zone at the Paramedic’s discretion, if it isin the patient’s best interest or if the transport to an appropriate facility is shorter.

L. The zones, hospitals in each zone, Zone Masters, and the Zone Master contact phone numbersare listed on EMSystem.

0100 GENERAL GUIDELINES: MANDATORY REPORTING OF ABUSE PATIENTS


Purpose

A. To provide guidelines for the reporting of suspected abuse patients.

Definition of Abuse:

A. Any recent act or failure to act on the part of a parent or caretaker which results in death, seriousphysical or emotional harm, sexual abuse or exploitation OR an act or failure to act whichpresents an imminent risk of serious harm.

Types of Abuse:

A. Types of maltreatment:1. neglect (majority of cases)2. physical abuse3. sexual abuse4. emotional abuse5. exploitation

Role of Mandated Reporter:

A. A mandatory reporter has reasonable cause to know or suspect that someone has beensubjected to abuse, neglect, or exploitation. He or she is to immediately report (within 24 hours)the information to local law enforcement or as directed by agency specific guidelines. Report canbe given in two ways:

1. Verbal report2. Written report

B. Mandatory reporters that do not report abuse, neglect, or exploitation can be:1. Charged with a class 3 misdemeanor2. Liable for damages proximately caused by failing to report

What to report:

A. The name, address, age, sex, and race of the child, at-risk elder, or at-risk adult with intellectualand developmental disability

B. The name(s) and address(es) of the person(s) responsible for the suspected abuse, neglect, orexploitation—if known

C. A description of the alleged mistreatment and the situationD. The nature and extent of any injuries—if knownE. Knowledge of previous cases of known or suspected abuse, neglect, or exploitation of the victim

or others under the person’s careF. The family composition, including any siblings or others in the householdG. The name, address and/or contact phone number, and occupation of the person making the

reportH. Relation of the person making report to the victim and/or how information was obtainedI. Any action taken by the reporting sourceJ. Any other information reporting person feels is important.

Additional Information:

A. An at-risk elder or at-risk adult with intellectual and developmental disability (per ColoradoRevised Statutes §18-6.5-102), or child who are suspected to be victims of abuse, neglect, orexploitation, as defined in Colorado Revised Statutes §19-3-304, should be reported in a mannerconsistent with agency guidelines/procedures within 24 hours.

B. Any “suspected” or known incident of abuse, neglect, or exploitation must be reportedC. Protecting patient confidentiality does not legally justify a failure to reportD. There is established immunity for reporters “acting in good faith”E. Domestic violence reporting is mandated if you are treating an adult with domestic assault injury

https://advance.lexis.com/api/document/collection/statutes-legislation/id/5PC1-8380-004D-108K-00008-00?cite=C.R.S.%2018-6.5-102&context=1000516

https://advance.lexis.com/api/document/collection/statutes-legislation/id/5PC1-8380-004D-108K-00008-00?cite=C.R.S.%2018-6.5-102&context=1000516

0110 GENERAL GUIDELINES: FREE-STANDING EMERGENCY DEPARTMENTS AS EMS DESTINATION


Purpose

A. A freestanding emergency department (FSED) is a facility that is structurally separate and distinct from ahospital and provides emergency care. There are two types of FSEDs:

1. A hospital outpatient department (HOPD), also referred to as an off-site hospital-based or satelliteemergency department (ED), these may be either hospital owned or hospital affiliated.

2. The second type of FSED is the independent freestanding emergency centers (IFECs).

B. The number of FSEDs is increasing rapidly with an ever-changing regulatory and health care environment.These facilities have various capability and capacity and the range of accepting ambulance patient is alsovariable.

C. For this reason, the appropriate utilization of these facilities as an ambulance destination should be at thediscretion of the local agency and agency medical director.

Recommendations

A. Hemodynamically stable patients may be considered for transport to a hospital-affiliated FSED with thefollowing exceptions:

1. No OB patients > 20 weeks estimated gestational age2. No trauma patients meeting RETAC trauma center destination guidelines.3. No alerts (e.g. STEMI, Stroke, Sepsis).4. No post-cardiac arrest patients with ROSC unless uncontrolled airway

B. Give consideration to the fact that elderly patients often require hospitalization for conditions such as falls,generalized weakness, dehydration, syncope. These patients should be targeted for full function hospital toavoid secondary transport

C. A psychiatric patient may exceed the capability of the FSED. The facility may not have security available orbe able to provide psychiatric evaluation. These patients should be transported to facilities with thecapabilities to meet patient’s needs.

D. When time and conditions allow, patients whom pre-hospital providers presume to require inpatientmanagement may be transported to a hospital emergency department to avoid subsequent patient transfers.

0120 GENERAL GUIDELINES: BASE CONTACT FOR PHYSICIAN CONSULTATION


Purpose

A. To explain the PGFPD Medical Director's expectations regarding base physician contact.

General Principles

A. The PGFPD protocols function as standing order treatment guidelines designed to reflectCDPHE Chapter 2 Rules pertaining to EMS practice and Medical Director oversight.Protocols are to be used as guidelines and cannot account for every patient scenario.Deviation from protocol may at times be justified and in the patient’s best interest. ThePGFPD we place great faith in the training and expertise of our EMS colleagues andtherefore wide latitude is granted throughout the protocol.

B. Base contact for physician consultation is not the same as emergency department pre-notification of patient arrival and handoff. Base contact may be used in multiple carescenarios including but not limited to: forewarning of unstable or complicated patients,patient refusal, and medical consultation and discussion.

C. Throughout the protocol patient “BASE CONTACT” is used to signify the need for call in.These algorithm points are set and agreed upon by the PGFPD and reflect criticaldecision points in care where communication with physician support is expected.

Preferred Base Contact Times.

A. The PGFPD group feels strongly that access to medical consultation should be readilyavailable at all times and utilized in the following circumstances:

1. Any time “BASE CONTACT” is required or recommended per protocol.2. Unusual presentations or patient care situations not covered by set protocol and

outside the scope of practice or comfort level of care by individual prehospitalprovider.

3. Necessary deviation from protocol deemed to be in the best interest of thepatient.

4. For selected patient care refusals as indicated by General Guidelines:Patient Non-Transport or Refusal.

5. During the care of critically ill patient who is not responding to protocol/algorithmic treatment.

0130 GENERAL GUIDELINES: TRANSPORTATION OF THE PEDIATRIC PATIENT


General Principles:

For the purpose of the protocols, pediatric patients are defined as <12 years of age. The unique anatomy, physiology and developmental needs of children in this age range affect prehospital care. Several specific differences include:

A. Airways are smaller, softer and easier to obstruct or collapse. Actions such as neck hyperflexion,hyperextension, or cricoid pressure may create an upper airway obstruction in a child

B. Respiratory reserves are small, resulting in the possibility of rapid desaturation in the setting of increaseddemand. One of the earliest signs of physiologic stress in a child may be an unexplained increase inrespiratory rate

C. Infants and young children utilize their abdominal musculature to assist with respirations. Tight,abdominally-placed straps used to secure children to spine boards may result in onset of or worseningrespiratory distress

D. Circulatory reserves are small. The loss of as little as one unit of blood can produce severe shock in aninfant.

E. Fluid overload is not a concern in children. 20 mL/kg boluses are always considered safe as the initialfluid resuscitation.

F. The developmental stage of a child impacts his/her ability to cooperate. The perception and memory ofpain is escalated by anxiety. Discuss or forewarn what will be done with any child over 2 years of age.Infants, especially those under 6 months of age, tolerate painful procedures better if allowed to suck on apacifier (especially if dipped in D25W) during the procedure. Utilize the parent or familiar guardianwhenever possible to distract/comfort (tell a story, sing a song, etc.) for all pediatric patients during painfulprocedures.

G. Vital signs on pediatric should include a blood pressure regardless of age. Providers should, if possible,make at least one attempt at obtaining a blood pressure on every pediatric patient.

Specific Consideration: Transportation safety

Children represent a unique challenge for safe transportation in emergency vehicles. The National Highway Traffic Safety Administration has established guidelines to ensure the safe restraint and positioning of children in emergency vehicles. Children should be restrained during transport. Transport of a child in a restrained adult’s arms is not recommended, but may be considered in special circumstances (i.e. severe croup, newborn). Transportation of children on the side bench seat in the rear compartment is also not recommended. The published goals are to prevent forward motion/ejection of the child, secure the torso, and protect the head, neck and spine in each of the following scenarios:

1. For a child who is not a patient, but requires transport to a facilityAll reasonable effort should be made to transport children who are not patients in a vehicle other thanthe ambulance. If transport in a vehicle other than an ambulance is not possible, transport in a size-appropriate child restraint system in the front passenger seat (with air bags off) or rear-facing EMSprovider’s seat in the ground ambulance

2. For a child who is injured/ill and whose condition does not require continuous monitoring orinterventionsTransport child in a size-appropriate child restraint system secured appropriately on a cot (rear-facing) or in an integrated seat in the EMS provider’s seat. Do not use a rear-facing child restraintsystem in a rear-facing EMS provider’s seat. If no child restraint system is available, secure the childon the cot using three horizontal restraints across the child’s chest, waist and knees and one verticalrestraint across each of the child’s shoulders. Remove any bulky clothing on child before restraining.Use blankets to maintain warmth.

3. For a child whose condition requires continuous or intensive monitoring or interventionsTransport child in a size-appropriate child restraint secured appropriately on a cot. If no child restraintsystem is available, secure the child on the cot using three horizontal restraints across the child’schest, waist and knees and one vertical restraint across each of the child’s shoulders.

4. For a child whose condition requires spinal precautions or lying flatPerform spinal immobilization procedure per protocol. Three points of restraint with shoulder straps isthe optimal for the patient. Avoid placing any restraints across the abdomen. Secure the patient, notjust the immobilization device to the stretcher. We do not recommend utilizing the child restraint

0130 GENERAL GUIDELINES: TRANSPORTATION OF THE PEDIATRIC PATIENT


system if spinal immobilization is required, as upright positioning places additional axial load on the patient’s neck and emergent airway intervention is not possible.

5. For a child requiring transport as part of a multiple patient transport (newborn with mother,multiple children, etc.)If possible, transport each as a single patient. When available resources prevent single patienttransportation, transport patients using safe, designated space available exercising extreme cautionand driving at reduced speeds. For mother and newborn, the newborn should be transported in arear-facing EMS provider seat using a convertible or integrated child restraint system. Do not use arear-facing child restraint system in a rear-facing EMS provider’s seat.

Transportation of the child with special health care needs:

Treat the child, not the equipment. Starting with the ABCs still applies to medically complicated or medical technology-assisted children.

A. The parent/guardian of a special needs child is the expert on that child and knows the details of thatillness, typical responses, and baseline interactions better than anyone. Utilize and trust his/herknowledge and concerns. This may include vital signs, medication responses, or physical positioning (i.e.of contracted limbs) that may not be typical.

B. Medically complicated children are often given healthcare notes describing their unique medical historyand emergency healthcare needs. Ask the parent/guardian for an emergency information sheet,emergency healthcare form, or QR code.

C. Ask the parent/guardian for the “go bag” for medical technology-assisted children. This will contain thechild’s spare equipment and supplies that may be needed on scene, during transport or in the hospital

D. Transport the child to their medical “home” hospital whenever possible

0140: Cancellation Policy

• To establish a policy in order to ensure that Emergency Medical Services are used efficiently and wisely throughout theCounty.

Policy Statement:

• This policy is to be used when there are no identifiable patients upon arrival on the scene.• A patient is defined as any person that:

• Requests medical assistance.• Demonstrates behavior indicating any type of injury or illness.• Law enforcement calls for a patient evaluation.

• When there are no patients on scene, additional responding units may be cancelled.• If patients are identified on scene, but are refusing treatment or transport to the hospital, then the Patient Non-

trasnport or Refusal Protocol 0080 will apply.• Under no circumstances will the air medical transport be cancelled by a responding Paramedic unit until an on scene

evaluation of the patient by the Paramedic is done and the need for the air medical transport is not indicated.


0150: Radio Report Format

• To establish a policy and procedure and format by which the medical providers of PGFPD will follow whencontacting the incoming ALS agency or when contacting the Emergency Department when transporting a patient.

Policy Statement:

The following information should be included in a radio report:

• Response: (emergent or routine)• Age of the patient.• Gender of the patient.• Mechanism of injury or the nature of the illness.• Chief complaint.• Level of consciousness.• Blood pressure.• Heart rate.• Respiratory rate.• Pulse oximetry reading.• Any procedures performed. (Example: Spinal immobilization. I.V. access. Oxygen administration. Intubation)• Trauma or medical team activation.• Estimated time of arrival.

**Note: If your patient is being transported by an air medical transport service, every effort should be made to contact the emergency room physician with your report.


0990 QUICK REFERENCE FOR PROCEDURES AND MEDICATIONS ALLOWED BY PROTOCOL

This list does not include Medical Director specific waivers or base contact requirements. It is assumed that not all agencies will necessarily stock all medications.

Abbreviations S = Standing order B = Base contact

Airway Procedures B BIV AEMT I P

Capnography S S S S S

Supraglottic airway S S S S S

Continuous positive airway pressure (CPAP) S S S S S

Orotracheal intubation S S

Nasotracheal intubation S

Percutaneous cricothyrotomy S

Bougie assisted surgical cricothyrotomy S

Pediatric needle cricothyrotomy S

Needle thoracostomy for tension pneumothorax decompression S S

Orogastric tube insertion with advanced airway S

Cardiovascular Procedures B BIV AEMT I P

Tourniquet S S S S S

ECG - Acquire (including 12-lead) S S S S S

ECG - Interpretation (including 12-lead) S S

Blood glucose monitoring S S S S S

IV – Peripheral S S S S

IV – External jugular S S S

IO

• Rescue or primary vascular access device when peripheral IV access notobtainable in a patient with critical illness

S S S S

• Utilization of IO access for all other patients B B B

Use of established central line (including PICC) for fluid and medication administration (must have appropriate equipment, e.g. Huber needle, and training to access subcutaneous ports)

S S

Automated / Semi-automated external defibrillator (AED) S S S S S

Defibrillation – Manual S S

Valsalva maneuver S

Synchronized cardioversion S

Transcutaneous cardiac pacing

• Adult S S

• Pediatric B B

Medications B BIV AEMT I P

Specialized prescription medications to address an acute crisis given the route of administration is within the scope of the provider

B B B B B

Adenosine (Adenocard)

• Adult B S

• Pediatric B B

Albuterol sulfate (MDI and nebulizer) S S S S S

Amiodarone

• Pulseless arrest B S

• Tachyarrhythmia with poor perfusion B

Antiemetic

• Ondansetron (Zofran) ODT S S S S S

• Ondansetron (Zofran) IV/IO S S S S

• Promethazine (Phenergan) B S

• Metoclopramide (Reglan) B S

• Droperidol - Adult B S

• Droperidol – Pediatric B B

Aspirin S S S S S

Atropine sulfate

• Hemodynamically unstable bradycardia B S

• Organophosphate poisoning and stable bradycardia B B




Benzodiazepines (midazolam, diazepam, lorazepam)

• Seizure B S

• Sedation for transcutaneous pacing or cardioversion B S

• Sedation for severely agitated or combative patient – Adult B S

• Sedation for severely agitated or combative patient – Pediatric B B

• Adjunctive agent for treatment of severe pain / muscle spasms B B

Calcium

• Pulseless arrest assumed due to hyperkalemia S

• Calcium channel blocker overdose B

Dextrose S S S S

Diphenhydramine (Benadryl) B B S

Dopamine S

Droperidol

• Adult B S

• Pediatric B B

Epinephrine

• Pulseless arrest – IV/IO S S

• Pediatric bradycardia – IV/IO B B

• Asthma – IM B S

• Anaphylaxis– IM S S S S S

• Pediatric severe systemic allergic reaction refractory to IM epinephrine - IV/IO B S

• Stridor at rest (alternative to racemic epinephrine) B S

• Epinephrine Auto-injector S S S S S

• Adult hypotension refractory to fluid resuscitation – IV drip S

• Adult bradycardia with signs of poor perfusion – IV drip S

• Adult severe systemic allergic reaction – IV drip S

Glucagon

• Hypoglycemia S S S

• Calcium channel blocker and β-blocker overdose B B S

Haloperidol (Haldol)

• Adult B S

• Pediatric B B

Hemostatic agents S S S S S

Hydroxocobalamin (Cyanokit) S S

Ipratropium Bromide (Atrovent) B B S

Lidocaine 2% Solution – Anesthetic for IO needle insertion S S S

Magnesium sulfate

• Torsades de pointes associated with prolonged QT interval S

• Refractory severe bronchospasm S

• Eclampsia B S

Methyprednisolone (Solu-Medrol) B S

Naloxone (Narcan) S S S S S

Nitroglycerin (Nitrostat, Nitroquick)

• Sublingual, patient assisted B B S S S

• Sublingual, agency supplied S S S

• Nitroglycerin paste B B S

Opioids

• Adult B S

• Pediatric (1-12 years) B S

• Pediatric (<1 year) B B

Oral glucose (Glutose, Insta-glucose) S S S S S

Oxygen S S S S S

Phenylephrine (Intranasal)

• Epistaxis S S S S S

• Prior to nasotracheal intubation S

Racemic epinephrine (Vaponephrine) B S




Sodium bicarbonate

• Pulseless arrest assumed due to hyperkalemia B S

• Tricyclic antidepressant overdose S

Topical ophthalmic anesthetics S S


1000 PROCEDURE PROTOCOL: OROTRACHEAL INTUBATION


Indications:

Respiratory failure

Absence of protective airway reflexes

Present or impending complete airway obstruction

Anticipated prolonged need for positive pressure ventilation

Contraindications:

There are no absolute contraindications. However, in general the primary goals of airwaymanagement are adequate oxygenation and ventilation, and these should be achieved in theleast invasive manner possible

o Orotracheal intubation is associated with worse outcomes among pediatric patientsand head injured patients when compared to BLS airway maneuvers. Therefore, it isrelatively contraindicated in these populations, and BLS airway is preferred unlesspatient cannot be oxygenated or ventilated by other means.

o Intubation is associated with interruptions in chest compressions during CPR, whichis associated with worse patient outcomes. Additionally, intubation itself has not beenshown to improve outcomes in cardiac arrest. Intubation should only be performedduring pulseless arrest if it does not cause interruptions in chest compressions.

Technique:

1. Initiate BLS airway sequence2. Suction airway and pre-oxygenate with BVM ventilations, if possible3. Check equipment and position patient:

a. If trauma: have assistant hold in-line spinal immobilization in neutral positionb. If no trauma, sniffing position or slight cervical hyperextension is preferred

4. Perform laryngoscopya. To improve laryngeal view, use right hand to manipulate larynx, or have assistant

apply backwards, upwards, rightward pressure (BURP)5. Place ETT. Confirm tracheal location and appropriate depth and secure tube

a. Correct tube depth may be estimated as 3 times the internal diameter of tube at teethor gums (e.g: 7.0 ETT is positioned at 21 cm at teeth)

6. Confirm and document tracheal location by:a. ETCO2, preferably with waveform capnographyb. Presence and symmetry of breath soundsc. Rising SpO2

d. Other means as needed7. Ventilate with BVM. Assess adequacy of ventilations8. During transport, continually reassess ventilation, oxygenation and tube position with

continuous waveform capnography and SpO2

Precautions:

Ventilate at age-appropriate rates. Do not hyperventilate

If the intubated patient deteriorates, think “DOPE”o Dislodgemento Obstructiono Pneumothoraxo Equipment failure (no oxygen)

Reconfirm and document correct tube position, preferably with waveform capnography, aftermoving patient and before disconnecting from monitor in ED

Unsuccessful intubation does not equal failed airway management. Many patients cannot beintubated without paralytics. Abandon further attempts at intubation and use supraglottic airway

or BVM ventilations if 2 attempts at intubation unsuccessful.

EMT-I Paramedic

1010 PROCEDURE PROTOCOL: NASOTRACHEAL INTUBATION


Indications:

Age 12 years and older spontaneously breathing patient with indication forintubation who cannot tolerate either supine position or laryngoscopyPresent or impending airway obstructionLack of protective airway reflexes

Contraindications:

ApneaSevere mid-face trauma

Technique:

1. Initiate BLS airway sequence and confirm ETCO2 production at this time.2. Suction airway and pre-oxygenate with BVM ventilations, if possible3. Check equipment, choose correct ETT size (usually 7.0 in adult, limit is size of naris)4. Position patient with head in midline, neutral position5. If trauma, cervical collar may be in place, or assistant may hold in-line stabilization in neutral

position6. If no trauma, patient may be sitting upright7. Administer phenylephrine nasal drops in each nostril8. Lubricate ETT with lidocaine jelly or other water-soluble lubricant9. With gentle steady pressure, advance the tube through the nose to the posterior pharynx. Use the

largest nostril. Abandon procedure if significant resistance is felt10. Keeping the curve of the tube exactly in midline, continue advancing slowly11. There will be slight resistance just before entering trachea. Wait for an inspiratory effort before

final passage through cords. Listen for loss of breath sounds12. Continue advancing tube until air is definitely exchanging through tube, then advance 2 cm more

and inflate cuff13. Note tube depth and tape securely14. Confirm and document endotracheal location by:

a. Continuous waveform capnographyb. Presence and symmetry of breath soundsc. Rising SpO2

15. Ventilate with BVM. Assess adequacy of ventilations16. During transport, continually reassess ventilation, oxygenation and tube position with continuous

waveform capnography and pulse oximetry

Precautions:

Before performing BNTI, consider if patient can be safely ventilated with non-invasive meanssuch as CPAP or BVMUse caution in anticoagulated or bleeding disorders given risk of epistaxis.Ventilate at age-appropriate rates. Do not hyperventilateIf the intubated patient deteriorates, think “DOPE”

o Dislodgemento Obstructiono Pneumothoraxo Equipment failure (no oxygen)

Reconfirm and document correct tube position with, preferably with waveform capnography aftermoving patient and before disconnecting from monitor in EDBlind nasotracheal intubation is a very gentle technique. The secret to success is perfectpositioning and patience.

Paramedic

1030 PROCEDURE PROTOCOL: CRICOTHYROTOMY


Introduction: Surgical cricothyrotomy is a difficult and hazardous procedure that is to be usedonly in extraordinary circumstances as defined below. The reason forperforming this procedure must be documented and submitted for review to theEMS Medical Director within 24 hours. Surgical cricothyrotomy is to be performed only byparamedics trained in this procedure.An endotracheal tube introducer (“bougie”) facilitates this procedure and has the advantage ofadditional confirmation of tube position and ease of endotracheal tube placement. If no bougie isavailable, the procedure may be performed without a bougie by introducing endotracheal tube ortracheostomy tube directly into cricothyroid membrane.Given the rarity and relative unfamiliarity of this procedure it may be helpful to have a medicalconsult on the phone during the procedure. Consider contacting base for all cricothyroidotomyprocedures. Individual Medical Directors may mandate base contact before initiating the procedure.Individual agency policy and procedures apply and providers are responsible for knowing andfollowing these policies.If using a commercially available cricothyrotomy kit, perform cricothyrotomy according tomanufacturer’s instructions.

Indications: A life-threatening condition exists AND advanced airway management is indicated AND you areunable to establish an airway or ventilate the patient by any other means. (“Cannot intubate/cannotventilate”)

Contraindications: Surgical cricothyrotomy is contraindicated in patients less than 12 years of age for anatomicreasons.

Technique: 1. Position the patient supine, with in-line spinal immobilization if indicated. If cervical spine injury not

suspected, neck extension will improve anatomic view.2. Clean skin per agency approved aseptic technique.3. Stabilize the larynx with the thumb and middle finger of your non dominant hand, and identify the

cricothyroid membrane with your index finger, typically 4 fingerbreadths below mandible4. Using a scalpel, make a 3 cm centimeter vertical incision 0.5 cm deep through the skin and fascia,

over the cricothyroid membrane. With finger, dissect the tissue and locate the cricothyroidmembrane.

5. Make a horizontal incision through the cricothyroid membrane with the scalpel blade oriented caudaland away from the cords. Remove scalpel blade and insert finger.

6. Insert the bougie curved-tip first through the incision and angled towards the patient’s feet guided bythe finger.

a. If no bougie available, use tracheal hook instrument to lift caudal edge of incision to facilitatevisualization and introduction of ETT directly into trachea and skip to # 9.

7. Advance the bougie into the trachea feeling for “clicks” of tracheal rings and until “hang-up” when itcannot be advanced any further. This confirms tracheal position.

8. Advance a 6-0 endotracheal tube over the bougie and into the trachea. It is very easy to place tubein right mainstem bronchus, so carefully assess for symmetry of breath sounds. Remove bougiewhile stabilizing ETT ensuring it does not become dislodged

9. Ventilate with BVM and 100% oxygen10. Confirm and document tracheal tube placement as with all advanced airways: Waveform

capnography as well as clinical indicators e.g.: symmetry of breath sounds, rising pulse oximetry,etc.

11. Secure tube with ties.12. Observe for subcutaneous air, which may indicate tracheal injury or extra- tracheal tube position13. Continually reassess ventilation, oxygenation and tube placement.

Precautions: Success of procedure is dependent on correct identification of cricothyroid membraneBleeding will occur, even with correct technique. Straying from the midline is dangerous and likely tocause hemorrhage.

Paramedic

1040 PROCEDURE PROTOCOL: PEDIATRIC NEEDLE CRICOTHYROTOMY


Introduction:

Needle cricothyrotomy is a difficult and hazardous procedure that is to be used only in extraordinarycircumstances as defined below. The rationale for this procedure must be documented in the patient carereport and submitted for review to the EMS Medical Director within 24 hours.Due to the funnel-shaped, rostral, highly compliant larynx of a pediatric patient, cricothyrotomy is an extremelydifficult procedure to successfully perform. As such, every effort should be made to effectively oxygenate thepatient before attempting needle cricothyrotomy.This protocol is considered optional and may not be adopted by all EMS Medical Directors or by all EMSagencies.A standardized, pre-prepared kit is recommended, and canbe assembled using common airway equipment. An exampleis given below. Kit selection may vary and should beapproved by the individual agency Medical Director.Example of kit:o 14 ga. and 16 ga. catheter over needleo 3 mL syringeo 15 mm endotracheal tube adaptor that fits the 3 mL

syringe used by agency (syringe barrel sizes vary)

Indications:

A life-threatening condition exists AND adequate oxygenation and ventilation cannot be accomplished byother less invasive means for patients < 12 years old.

Contraindications:

If patient can be ventilated and oxygenated by less invasive means

Technique:

1. Ensure patent upper airway with placement of an oral airway and nasal airway, unless contraindicated.2. Open pre-prepared kit, attach angiocath to syringe, and aspirate 1-2 mL of saline into syringe3. Prepare skin using aseptic solution4. Insert the IV catheter through the skin and cricothyroid membrane into the trachea. Direct the needle at a

45° angle caudally (toward the feet). When the needle penetrates the trachea a “pop” will be felt.5. Aspirate with the syringe. If air is retuned easily or bubbles are seen (with saline), the needle is in the

trachea.6. Advance the catheter over the needle while holding the needle in position, then withdraw needle after

catheter is advanced flush to skin.7. Remove the plunger and attach the 3 mL syringe to the catheter hub8. Attach the 15 mm adaptor to the needle hub9. Oxygenate the patient with bag-valve-mask device using the 15 mm adaptor provide high flow oxygen.10. Confirm and document catheter placement by:

a. Waveform capnographyb. Rising pulse oximetry

11. Do not let go of catheter and be careful not to kink the catheter. There is no reliable way to secure itin place, and it is only a temporizing measure until a definitive airway can be established at the hospital

12. Observe for subcutaneous air, which may indicate tracheal injury or extra- tracheal catheter position13. Continually reassess oxygenation and catheter position.

Paramedic

1050 PROCEDURE PROTOCOL: SUPRAGLOTTIC AIRWAY


Indications: Rescue airway if unable to intubate a patient in need of airwayprotectionPrimary airway if intubation anticipated to be difficult and rapid airwaycontrol is necessaryPrimary airway in pulseless arrest, when attempts at intubation arelikely to interrupt CPRDesignated advanced airway for EMTsPreferred advanced airway in the pediatric patient

Contraindications: Intact gag reflexCaustic ingestion

Technique: 1. Initiate BLS airway sequence2. Select proper size supraglottic airway based on manufacturer’s specifications3. Assemble equipment, note correct volume for inflation marked on tube itself, test balloon for

leaks, lubricate posterior aspect distal tip with water-soluble lubricant4. Suction airway and maximize oxygenation with BVM ventilations5. If trauma: have assistant hold in-line spinal immobilization in neutral position6. If no trauma, sniffing position or slight cervical hyperextension is preferred7. Place supraglottic airway utilizing device-specific technique8. Inflate cuff balloon with correct volume of air (marked on device)9. Confirm tube placement by auscultation, chest movement, and waveform capnography10. Continuously monitor waveform capnography, SpO2, vital signs

Precautions: 1. Do not remove a properly functioning supraglottic airway in order to attempt intubation2. Correct sizing of supraglottic airways is critical for correct function3. Supraglottic airways are safe and effective in pediatric patients, provided the correct size tube

is selected. The age-range for supraglottic airway use is dependent on the specific devicebeing used. Providers should be trained on and familiar with correct size selection for theirdevice.

4. Use with caution in patients with broken teeth, which may lacerate balloon.5. Use with caution in patients with known esophageal disease who are at increased risk of

esophageal injury.

EMT AEMT

EMT-I Paramedic

1060 PROCEDURE PROTOCOL: CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)


Indications:

Symptomatic patients with moderate-to-severe respiratory distress asevidenced by at least two (2) of the following:

o Rales (crackles)o Dyspnea with hypoxia (SpO2 less than 90% despite O2)o Dyspnea with verbal impairment – i.e. cannot speak in full

sentenceso Accessory muscle useo Respiratory rate greater than 24/minute despite O2

o Diminished tidal volume

Contraindications:

Respiratory or cardiac arrest

Systolic BP less than 90mmHg

Lack of airway protective reflexes

Significant altered level of consciousness such that unable to follow verbal instructions or signaldistress

Vomiting or active upper GI bleed

Suspected pneumothorax

Trauma

Patient size or anatomy prevents adequate mask seal

Technique: 1. Place patient in a seated position and explain the procedure to him or her2. Assess vital signs (BP, HR, RR, SpO2, and ETCO2)3. Apply the CPAP mask and secure with provided straps, progressively tightening as tolerated to

minimize air leak4. Operate CPAP device according to manufacturer specifications5. Start with the lowest continuous pressure that appears to be effective. Adjust pressure following

manufacturer instructions to achieve the most stable respiratory status utilizing the signsdescribed below as a guide

6. Monitor patient continuously, record vital signs every 5 minutes.7. Assess patient for improvement as evidenced by the following:

a. Reduced dyspneab. Reduced verbal impairment, respiratory rate and heart ratec. Increased SpO2

d. Stabilized blood pressuree. Appropriate ETCO2 values and waveformsf. Increased tidal volume

8. Observe for signs of deterioration or failure of response to CPAP:a. Decrease in level of consciousnessb. Sustained or increased heart rate, respiratory rate or decreased blood pressurec. Sustained low or decreasing SpO2 readingsd. Rising ETCO2 levels or other ETCO2 evidence of ventilatory failuree. Diminished or no improvement in tidal volume

Precautions:

Should patient deteriorate on CPAP:o Troubleshoot equipmento Consider endotracheal intubationo Assess need for possible chest decompression due to pneumothoraxo Assess for possibility of hypotension due to significantly reduced preload from positive

pressure ventilation

In-line nebulized medications may be given during CPAP as indicated and in accordance withmanufacturer guidelines

Some fixed pressure CPAP devices do not have FiO2 adjustment and will only administer up to30% oxygen. If no improvement in oxygenation with a fixed pressure CPAP device, consideradding supplemental oxygen.

EMT AEMT

EMT-I Paramedic

1070 PROCEDURE PROTOCOL: CAPNOGRAPHY


Indications: A. MANDATORY: to rule out esophageal intubation and confirm endotracheal tube position in all

intubated patients.B. To identify late endotracheal tube dislodgementC. To monitor ventilation and perfusion in any ill or injured patient

Contraindications: A. None

Technique: A. In patient with ETT or advanced airway: place ETCO2 detector in-line between airway adaptor

and BVM after airway positioned and securedB. Patients without ETT or advanced airway in place: place ETCO2 cannula on patient. May be

placed under CPAP or NRB facemaskC. Assess and document both capnography waveform and ETCO2 value

Precautions: A. To understand and interpret capnography, remember the 3 determinants of ETCO2:

1. Alveolar ventilation2. Pulmonary perfusion3. Metabolism

B. Sudden loss of ETCO2:1. Tube dislodged2. Circuit disconnected3. Cardiac arrest

C. High ETCO2 (> 45)1. Hypoventilation/CO2 retention

D. Low ETCO2 (< 25)1. Hyperventilation2. Low perfusion: shock, PE, sepsis

E. Cardiac Arrest:1. In low-pulmonary blood flow states, such as cardiac arrest, the primary determinant of

ETCO2 is blood flow, so ETCO2 is a good indicator of quality of CPR2. If ETCO2 is dropping, change out person doing chest compressions3. In cardiac arrest, if ETCO2 not > 10 mmHg after 20 minutes of good CPR, this likely

reflects very low CO2 production and is associated with poor outcome4. Sudden rise in EtCO2 may be an indicator of ROSC

EMT AEMT EMT-I Paramedic

1080 PROCEDURE PROTOCOL: NEEDLE THORACOSTOMY FOR TENSION PNEUMOTHORAX DECOMPRESSION


Indications:

A. All of the following clinical indicators must be present:1. Severe respiratory distress2. Hypotension3. Unilateral absent or decreased breath sounds

B. Perform bilateral needle chest decompression in traumatic pulseless arrest if any traumato trunk

Technique:

A. Expose entire chestB. Clean skin overlying site with available skin prepC. Insert angiocath either at 2nd intercostal space at midclavicular line, or 5th intercostal

space at midaxillary line1. Either approach is acceptable, generally the site with the least soft tissue

overlying ribs is preferred2. For adult, use largest, longest available angiocath. For children, a shorter

angiocath is appropriate.D. Notify receiving hospital of needle decompression attempt

Precautions:

A. Angiocath may become occluded with blood or by soft tissueB. A simple pneumothorax is NOT an indication for needle decompressionC. Extra care is needed when performing on a pediatric patient.

EMT-I Paramedic

1090 PROCEDURE PROTOCOL: SYNCHRONIZED CARDIOVERSION


Unstable tachyarrhythmia with a pulse

Check:

• O2 via NRB facemask

• Functioning IV line

• Suction

• Advanced airway equipment ready

Sedate with benzodiazepine if not contraindicated

Continue treatment according to Tachycardia with Poor Perfusion

Precautions:

• If rhythm is AV nodal reentrant tachycardia (AVNRT, historically referred to as “PSVT”) it ispreferred to attempt a trial of adenosine prior to electrical cardioversion, even if signs of poorperfusion are present, due to rapid action of adenosine

• If defibrillator does not discharge in “synch” mode, then deactivate “synch” and reattempt

• If sinus rhythm achieved, however briefly, then dysrhythmia resumes immediately, repeatedattempts at cardioversion at higher energies are unlikely to be helpful. First correct hypoxia,hypovolemia, etc. prior to further attempts at cardioversion

• If pulseless, treat according to Universal Pulseless Arrest Algorithm

• Chronic atrial fibrillation is rarely a cause of hemodynamic instability, especially if rate is < 150bpm. First correct hypoxia, hypovolemia, before considering cardioversion of chronic atrialfibrillation, which may be difficult, or impossible and poses risk of stroke

• Sinus tachycardia rarely exceeds 150 bpm in adults or 180 bpm in children and does not requireor respond to cardioversion. Treat underlying causes.

• Transient dysrhythmias or ectopy are common immediately following cardioversion and rarelyrequire specific treatment other than supportive care

Paramedic

Adult

200 Joules biphasic

Pediatric

Perform Synchronized Cardioversion

0.5-1 Joules/kg biphasic

1100 PROCEDURE PROTOCOL: TRANSCUTANEOUS CARDIAC PACING


Indications 1. Symptomatic bradyarrhythmias (includes A-V block) not responsive to

medical therapy2. Pacing is rarely indicated in patients under the age of 12 years.

CONTACT BASE

Precautions 1. Conscious patient will experience discomfort; consider sedation with benzodiazepine if blood

pressure allows.

Contraindications 1. Pacing is contraindicated in pulseless arrest.

Technique 1. Apply electrodes as per manufacturer specifications: (-) left anterior, (+) left posterior.2. Turn pacer unit on.3. Set initial current to 80 mAmps.4. Select pacing rate at 80 beats per minute (BPM)5. Start pacing unit.6. Confirm that pacer senses intrinsic cardiac activity by adjusting ECG size.7. If no initial capture, increase current 10 mAmps every 10-15 seconds until capture or 200 mAmps

(usually captures around 100 mAmps).8. Check for femoral pulse once there is electrical capture.9. If no capture occurs with maximum output, discontinue pacing and resume ACLS.

Complications 1. Ventricular fibrillation and ventricular tachycardia are rare complications, but follow appropriate

protocols if either occur.2. Muscle tremors may complicate evaluation of pulses; femoral pulse may be more accurate.3. Pacing may cause diaphragmatic stimulation and apparent hiccups.

EMT-I Paramedic

1110 PROCEDURE PROTOCOL: INTRAOSSEUS CATHETER PLACEMENT


Indications:

1. Rescue or primary vascular access device whenperipheral IV access not obtainable in a patient with critical illness defined as any of the following:

A. Cardiopulmonary arrest or impending arrestB. Profound shock with severe hypotension and poor perfusionC. Hypoglycemia with severe symptoms (e.g. unresponsive) and no venous access

2. Utilization of IO access for all other patients requires base station contact (NOT indicated for EMT-IV)

Technique: 1. Site of choice – typically proximal tibia. Other sites such as distal femur or humeral head may be

considered based on clinical presentation if authorized by agency Medical Director after completion ofappropriate training.

2. Clean skin with povidone-iodine.3. Place intraosseous needle perpendicular to the bone.

A. For infants less than 6 months consider manual insertion of needle rather than powered device toavoid puncturing through both sides of the bone.

4. Follow manufacturer’s guidelines specific to the device being used for insertion.5. Entrance into the bone marrow is indicated by a sudden loss of resistance.6. Flush line with 10 mL saline. Do not attempt to aspirate marrow

A. IO infusion is very painful. If the patient is conscious, administer lidocaine for pain control beforeinfusing fluids or medications.

7. Secure lineA. Even if properly placed, the needle will not be secure. The needle must be secured and the IV

tubing taped. The IO needle should be stabilized at all times.8. Observe for signs of limb swelling, decreased perfusion to distal extremity that would indicate a

malpositioned IO catheter or other complication. If limb becomes tense or malperfused, disconnect IOtubing immediately and leave IO in place.

9. A person should be assigned to monitor the IO at the scene and en route to the hospital.10. Do not make more than one IO placement attempt per bone.11. Do not remove IO needles in the field.12. Notify hospital staff of all insertion sites/attempts and apply patient wristband included with kit to identify

IO patient.

Complications: 1. Fracture2. Compartment syndrome3. Infection

Contraindications: 1. Fracture of target bone2. Cellulitis (skin infection overlying insertion site)3. Osteogenesis imperfecta (rare condition predisposing to fractures with minimal trauma)4. Total knee replacement (hardware will prevent placement)

Side Effects and Special Notes: 1. IO placement may be considered prior to peripheral IV attempts in critical patients without identifiable

peripheral veins2. Some authorities recommend aspiration of marrow fluid or tissue to confirm needle location. This is not

recommended for field procedures, as it increases the risk of plugging the needle.3. Expect flow rates to be slower than peripheral IVs. Pressure bags may be needed. Any drug or IV fluid

may be infused.4. Some manufacturers recommend the use of lidocaine for the treatment of pain associated with fluid

administration. Check with your manufacturer and Medical Director for further guidance

EMT -IV ONLY

AEMT EMT-I Paramedic

1120 PROCEDURE PROTOCOL: TOURNIQUET PROTOCOL


Indications

A. A tourniquet should be used for initial control of life threateninghemorrhage.

Precautions

A. In cases of life-threatening bleeding, benefit of tourniquet use outweighs any theoretical riskof limb ischemia.

B. A commercially made tourniquet is the preferred tourniquet. If none is available, a bloodpressure cuff inflated to a pressure sufficient to stop bleeding is an acceptable alternative.

Technique

A. First, attempt to control hemorrhage by using direct pressure over bleeding area.B. If a discrete bleeding vessel can be identified, point pressure over bleeding vessel is more

effective than a large bandage and diffuse pressure.C. If unable to control hemorrhage using direct pressure, apply tourniquet according to

manufacturer specifications and using the steps below:1. Cut away any clothing so that the tourniquet will be clearly visible. NEVER obscure a

tourniquet with clothing or bandages.2. Apply tourniquet proximal to the wound and not across any joints.3. Tighten tourniquet until bleeding stops. Applying tourniquet too loosely will only increase

blood loss by inhibiting venous return.4. If bleeding is not controlled with the application of a single tourniquet, a 2nd can be

applied adjacent to the 1st.5. Mark the time and date of application on the patient’s skin next to the tourniquet.6. Keep tourniquet on throughout hospital transport – a correctly applied tourniquet should

only be removed by the receiving hospital.7. Pain management as needed.

EMT

EMT-I Paramedic

AEMT

1130 PROCEDURE PROTOCOL: RESTRAINT PROTOCOL


Indications: A. Physical restraint of patients is permissible and encouraged if the patient poses

a danger to him/herself or to others. Only reasonable force is allowable, i.e.,the minimum amount of force necessary to control the patient and preventharm to the patient or others. Try alternative methods first (e.g., verbal de-escalation should be used first if the situation allows).

B. Paramedic: Consider pharmacological sedation for agitated patients thatrequire transport and are behaving in a manner that poses a threat to him/herself or others.

1. See Agitated/Combative Patient Protocol: (The term “chemical restraint” is no longer preferred)C. Restraints may be indicated for patients who meet the following criteria:

1. A patient who is significantly impaired (e.g. intoxication, medical illness, injury, psychiatriccondition, etc) and lacks decision-making capacity regarding his or her own care.

2. A patient who exhibits violent, combative or uncooperative behavior who does not respond toverbal de-escalation.

3. A patient who is suicidal and considered to be a risk for behavior dangerous to his or herself or tohealthcare providers.

4. A patient who is on a mental health hold.Precautions:

A. When appropriate, involve law enforcementB. Restraints shall be used only when necessary to prevent a patient from seriously injuring him/herself or

others (including the EMS providers), and only if safe transportation and treatment of the patient cannotbe accomplished without restraints. They may not be used as punishment, or for the convenience of thecrew.

C. Any attempt to restrain a patient involves risk to the patient and the prehospital provider. Efforts torestrain a patient should only be done with adequate assistance present.

D. Be sure to evaluate the patient adequately to determine his or her medical condition, mental status anddecision-making capacity.

E. Do not use hobble restraints and do not restrain the patient in the prone position or any position thatimpairs the airway or breathing.

F. Search the patient for weapons.G. Handcuffs are not appropriate medical restraints and should only be placed by law enforcement

personnel. See Transport of Handcuffed Patient Protocol.Technique:

A. Treat the patient with respect. Attempts to verbally reassure or calm the patient should be done prior tothe use of restraints. To the extent possible, explain what is being done and why.

B. Have all equipment and personnel ready (restraints, suction, a means to promptly remove restraints).C. Use assistance such that, if possible, 1 rescuer handles each limb and 1 manages the head or supervises

the application of restraints.D. Apply restraints to the extent necessary to allow treatment of, and prevent injury to, the patient. Under-

restraint may place patient and provider at greater risk.E. After application of restraints, check all limbs for circulation. During the time that a patient is in restraints,

continuous attention to the patient’s airway, circulation and vital signs is mandatory. A restrained patientmay never be left unattended.

Documentation Document the following in all cases of restraint: A. Description of the facts justifying restraintB. Efforts to de-escalate prior to restraintC. Type of restraints usedD. Condition of the patient while restrained,

including reevaluations during transport

E. Condition of the patient at the time of transferof care to emergency department staff

F. Any injury to patient or to EMS personnel

Complications: A. Aspiration: continually monitor patient’s airwayB. Nerve injury: assess neurovascular status of patient’s limbs during transportC. Complications of medical conditions associated with need for restraint

1. Patients may have underlying trauma, hypoxia, hypoglycemia, hyperthermia, hypothermia, drugingestion, intoxication or other medical conditions

D. Excited Delirium Syndrome. This is a life-threatening medical emergency. These patients are truly out ofcontrol. They will have some or all of the following symptoms: paranoia, disorientation, hyper-aggression,hallucination, tachycardia, increased strength, and hyperthermia.

EMT AEMT

EMT-I Paramedic

1140 PROCEDURE PROTOCOL: OROGASTRIC TUBE INSERTION WITH ADVANCED AIRWAY


Indications:

• Gastric decompression in the intubated patient

• Gastric decompression with placement of supraglottic airway

• Intended for agencies with prolonged transport times in situations where time and conditions allowgastric decompression without interruption of routine care

Contraindications:

• Known esophageal varices

Technique:

1. Determine length of tube for insertion. Measure from tip of nose, to earlobe, then down to xiphoidprocess

2. Liberally lubricate the distal end of the orogastric tube3. Suction airway and pre-oxygenate with BVM ventilations, if possible4. Insert tube:

a. For orotracheal and nasotracheal intubation, insert tube into patient’s mouth; continue toadvance the tube gently until the appropriate distance is reached

b. For supraglottic airway, insert tube through gastric access lumen and continue toadvance tube till appropriate distance is reached.

5. Confirm placement by injecting 30cc of air and auscultate for the swish or bubbling of the air overthe stomach. Aspirate gastric contents to confirm proper placement.

6. Secure with tape to inserted airway and attach to low continuous suction if indicated

Paramedic

1150 PROCEDURE PROTOCOL: TASER® PROBE REMOVAL


Indications

Patient with TASER® probe(s) embedded in skin.

Contraindications

TASER® probe embedded in the eye or genitals. In such cases, transportpatient to an emergency department for removal.

Technique

1. Confirm the TASER® has been shut off and the barb cartridge has been disconnected. .

2. Using a pair of shears cut the TASER® wires at the base of the probe.

3. Place one hand on the patient in area where the probe is embedded and stabilize the skinsurrounding the puncture site. Using the other hand (or use pliers) firmly grasp the probe.

4. In one uninterrupted motion, pull the probe out of the puncture site maintaining a 90° angle to theskin. Avoid twisting or bending the probe.

5. Repeat the process for any additional probes.

6. Once the probes are removed, inspect and assure they have been removed intact. In the event theprobe is not removed intact or there is suspicion of a retained probe, the patient must betransported to the emergency department for evaluation.

7. Cleanse the probe site and surrounding skin with betadine and apply sterile dressing.

8. Advise patient to watch for signs of infection including increased pain at the site, redness swellingor fever.

EMT AEMT

EMT-I Paramedic

1160: Cardiac Monitor - 4 Lead EKG

Indications:

• Chest or mid - epigastric discomfort / pain.• Irregular pulse.• Dyspnea with a history of cardiac disease.• Weakness / dizziness / diaphoresis.• Near syncopal episode or actual syncopal episode.

Contraindications

• None listed.

Precautions / Notes:

• Verify correct lead placement.

Lead Placement:

Lead Color Position to be placed

Black Lead Left Arm

3 - Lead 4 - Lead

5 - Lead

White Lead Right Arm

Red Lead Left Leg

Green Lead Right Leg

Brown Lead 4th Intercostal Space Right of Sternum

Technique / Procedure:

• Application of electrodes.• Record ECG rhythm strip.• Interpret the EKG rhythm: (Intermediates & Paramedics Only)

Procedure: FR EMT B EMT IV AEMT EMT I EMT P

• Cardiac Monitor: Application & acquisition of 4 lead. SO SO SO SO SO

• Cardiac Monitor: Interpretation of 4 lead EKG. SO SO


1170: Cardiac Monitor - 12 Lead EKG

Indications:

• Chest or mid - epigastric discomfort / pain.• Irregular pulse / dysrhythmia / or some type of block on the 4 lead EKG monitor.• Complaining of dyspnea with a history of cardiac disease.• Weakness / dizziness / diaphoresis between the ages of 35 to 80• Near syncopal episode or actual syncopal episode.• To be done on patients post cardiac arrest during transport if time allows.

Contraindications:

• None listed.


• Do not delay treatment or transport for 12 lead EKG acquisition.• Patients experiencing an inferior wall myocardial infarction may also be having a right ventricular wall myocardial

infarction. Therefore patients with an inferior wall myocardial infarction should also have a V4R lead view run inaddition to a 12 lead EKG to rule out right ventricular involvement.

Lead Placement:


1190: Pulse Oximetry Monitoring

Indications:

• Any medical complaint or traumatic injury.• The pulse oximeter may be used in a variety of situations that require monitoring of oxygen status.

• The pulse oximeter displays a digital percentage readout of a calculated estimate of the patient’s hemoglobin thatis saturated with oxygen and heart rate.

• The pulse oximeter can provide an early warning of decreasing arterial oxyhemoglobin saturation prior to thepatient exhibiting clinical signs of hypoxia.

• The pulse oximeter can be used as a guide for determining therapeutic oxygen requirements.• The pulse oximeter can be used to monitor the effectiveness of oxygenation and ventilation therapy.

Contraindications:

• None listed.


• Pulse oximetry equipment must be maintained per the manufacturer and FDA guidelines.• Pulse oximetry is not a substitute for conducting a thorough assessment of your patient.• Never withhold oxygen from a patient in distress while waiting for a reading or if the reading indicates above normal.• Results may be affected by any vascular impairment such as:

• Elevation of the extremity in relation to the heart.• Compression of the finger by the probe or excessive taping.• Vasoconstrictors such as cold, fear, hypothermia, and medications.• AV fistula decreasing distal flow.• Poor peripheral perfusion.• Carbon monoxide poisoning.• Hypovolemia.

• Potential causes for interference with pulse oximeter readings:• Artificial nails.• Dark pigmentation.• Electrical.• Movement.• Radiated (bright) light.• Edema.• Pigments.

Note: Oxygen saturation values are guidelines only. EMS personnel must consider the patient’s overall condition!!


1190: Pulse Oximetry Monitoring


• Press the power button to turn the pulse oximeter on.• Place the finger probe on the patient’s finger, toe, nose, or ear lobe.• Initial reading will be the patient’s oxygen saturation level.

Interpret the pulse oximeter reading: • In 3 to 6 seconds the pulse rate and oxygen saturation readings are displayed.• Readings are averaged over 5 to 15 seconds.• Normal oxygen saturation is considered to range between 97% to 99%.• Normal levels of oxygen saturation are greater than 93% at our altitude.• If oxygen saturation is below 92% consider further oxygen therapy and treatment.• Readings of 90% or less may indicate that the patient needs supplemental oxygen.


• Pulse Oximetry Monitoring PPA SO SO SO SO SO


1200: Splinting - Extremity

Indications:

• An extremity fracture site requiring immobilization for transport.• An extremity sprain sites requiring immobilization for transport.• Dislocations requiring immobilization for transport.

Contraindications:

• None listed.


• While grotesque looking, extremity fractures are rarely life threatening. Do not overlook life threatening injuries.• Multiple extremity fractures are indicative of significant mechanism of injury & possibly other life threatening injuries.• Be sure to address significant bleeding as per the Hemorrhage Control protocol.• Generally splint the injury as found with an appropriate method.• Severe deformities with signs of compromised circulation are allowed one re - alignment in the field.• Assure PMSC distal to the injury prior to and after the splinting.• Consider pain management: Refer to Section 1230 for medications addressing pain.

Technique / Procedure: Extremity Splinting

• Expose the fracture site.• Check for distal pulses, movement, sensation, and circulation.• Dress and bandage any wounds prior to splinting.• May need to re - align severely angulated fractures if no distal pulses are present. (One re - alignment in the field)• Joint injuries should be immobilized in the position found.• Immobilize the joint above and below the fracture site.• Pelvic injuries can be stabilized using a sheet tightly wrapped around the patient's pelvis.• An inverted K.E.D. device may also be used to stabilize the pelvis.• The type of splint will be dependant on the type and location of the fracture.• Secure the splint with Kerlix and tape. Secure to immobilize the extremity but not impair circulation.• After the splint is applied, the patient should be re - evaluated for pulses, movement, sensation, and circulation.


Section 1200: Splinting - Extremity

Technique / Procedure: Traction Splints

• Expose the fracture site.• Check for distal pulses, movement, sensation, and circulation.• Dress and bandage any wounds prior to splinting.• Place the ankle hitch on the injured leg and apply gentle traction.• Position the splint under the leg supporting fracture site. Ischial pad should be placed against the ischial tuberosity.• Attach the ankle hitch to the splint and carefully increase the amount of traction. Titrate to the patient's comfort.• Secure the leg straps. Avoid placing the straps over the fracture site or the knee.• An inverted K.E.D. device may also be used to stabilize the pelvis.• After the splint is applied, the patient should be re - evaluated for pulses, movement, sensation, and circulation.


• Traction splinting. SO SO SO SO SO


1210: Suctioning - Endotracheal

Indications:

• Endotracheal suctioning should be used to remove excess foreign material that can't be removed by a suction device.

Contraindications:

• None listed.


• Complications may be caused both by inadequate and overly vigorous suctioning. Technique and choice of equipmentare very important. Choose equipment with enough power to suction large amounts rapidly to allow for ventilation.

• Proper airway clearance can make the difference between a patient who survives and one who dies. Airwayobstruction is one of the most common treatable causes of pre - hospital death.

Complications:

• Cerebral anoxia may occur as a result of excessive suctioning time without adequate oxygenation between attempts.• Persistent obstruction due to inadequate tubing for removal of debris.• Lung injury from aspiration of stomach contents due to inadequate suctioning.• Asphyxia due to recurrent obstruction if airway is not monitored after initial suctioning.• Vomiting and aspiration from stimulation of gag reflex.• Induction of cardio pulmonary arrest from vagal stimulation.

Technique / Procedure

• Advance the catheter tip down the endotracheal tube as far as possible or until resistance is met.• Apply suction and withdraw catheter slowly not to exceed 10 to 15 seconds.

Note: Suctioning should only be done with a sterile catheter.• Rinse catheter tip in sterile water or saline if re - using.• Continued ventilations between suctioning attempts.


• Adult Suctioning: Endotracheal Route. SO SO

• Neonatal Suctioning: Endotracheal Route SO SO


1220: Suctioning - Pharyngeal

Indications:

• Pharyngeal suctioning should be used to remove excess foreign material that can be removed by a suction device.

Contraindications:

• None listed.


• Complications may be caused both by inadequate and overly vigorous suctioning. Technique and choice of equipmentare very important. Choose equipment with enough power to suction large amounts rapidly to allow for ventilation.

• Proper airway clearance can make the difference between a patient who survives and one who dies. Airwayobstruction is one of the most common treatable causes of pre - hospital death.

Complications:

• Cerebral anoxia may occur as a result of excessive suctioning time without adequate oxygenation between attempts.• Persistent obstruction due to inadequate tubing for removal of debris.• Lung injury from aspiration of stomach contents due to inadequate suctioning.• Asphyxia due to recurrent obstruction if airway is not monitored after initial suctioning.• Conversion of partial to complete obstruction by attempts at airway clearance.• Trauma to the posterior pharynx from forced use of equipment.• Vomiting and aspiration from stimulation of gag reflex.• Induction cardio pulmonary arrest from vagal stimulation.


1220: Suctioning - Pharyngeal


• Turn patient on side if possible, to facilitate clearance.• Open airway and inspect for visible foreign material.• Remove large or obvious foreign matter with gloved hands. Use tongue blade or oropharyngeal airway (do not pry) to

keep airway open. Sweep finger across posterior pharynx and clear material out of mouth.

Adult Suctioning of the Oropharynx:

• Attach a tonsil tip. (Use open end for large amounts of debris)• Insert tip into the oropharynx under direct visualization, with sweeping motion.• Continue to oxygenate between 10 to 15 seconds.

Suctioning of the Newborn:

• Use neonatal suctioning device. Most common is a bulb syringe.• As soon as infant's head has delivered, insert the suction tip into the mouth and back to the oropharynx.• Apply suction while slowly withdrawing catheter from the mouth.• Insert the catheter tip into each nostril and back to the posterior pharynx.• Apply suction while slowly withdrawing catheter from each nostril.• As soon as infant has delivered repeat the process.• If meconium staining is present be prepared to suction infant via endotracheal route.


1230 PROCEDURE PROTOCOL: PAIN MANAGEMENT


Goal of Pain Management

A. Use comfort measure therapies as first line.B. If used, medications should be administered to a point where pain is tolerable.

This point is not necessarily pain free.

Assessment

A. Determine patient’s pain assessment and consider using a pain scale:

1. Pediatric use observational scale (see Pediatric Pain Scales)2. Adult Self-report scale (Numeric Rating Scale [NRS])

B. Categorize the assessment of pain to mild, moderate, or severe.

1. Overreliance on pain scores may lead to either inadequate pain control in stoic patients, or over sedationin patients reporting high levels of pain. Use subjective and objective findings to evaluate need for andefficacy of pain management.

2. For pediatric patients, pain scale use is recommended. A pain score of 0-3 is mild pain, scores from 4-6 moderate pain, and 7-10 severe pain.

General Pain Management Technique

EMT AEMT

EMT-I Paramedic

Use comfort measure therapies as first line:

• Place patient in position of comfort

• Splint/support painful area

• Apply ice, if applicable

• Consider compression, if applicable

Mild pain Moderate pain

Consider acetaminophen/NSAID

Consider titration of opioids until pain tolerable or dosing maximized

Consider acetaminophen/NSAID

Contact Base or follow agency

specific guidelines for pain that is

not managed with opioids or if there

are specific circumstances where

opioids should not be administered

Severe pain

Consider IV titration of opioids until pain tolerable or dosing maximized

For severe pain consider IN administration of opioid if IV not

readily available

• Transport in position of comfortand reassess as indicated

• Consider and prepare for

administration of antiemetic if

patient develops nausea and/or

vomiting after pain medication

Some conditions are complex and may be

harmed by opioid use. It may be better to have

physician evaluation prior to opioid use. These

conditions include:

• Headaches

• Chronic abdominal pain

May add acetaminophen/NSAID

1230 PROCEDURE PROTOCOL: PAIN MANAGEMENT


General Information

A. Document assessment or pain scale before and after administration of pain medications. Reassess pain 5minutes after IV administration.

B. Strongly consider ½ typical dosing in the elderly or frail patient

Pediatric Pain Scales

Recommended Pain Scale for Ages 4-12 Years

Faces Pain Scale – Revised (FPS-R)

0 2 4 6 8 10 This Faces Pain Scale-Revised has been reproduced with permission of the International Association for the Study of Pain® (IASP). The

figure may NOT be reproduced for any other purpose without permission.

1240 PROCEDURE PROTOCOL: SAM PELVIC SLING II

Indications:

• Suspected pelvic ring fracture

• Closed Open Book Pelvic fracture

Contraindications:

• Open pelvic fracture

• Suspected femoral neck fracture

• Suspected hip dislocation

Technique

1. Check for distal pulses before and after application 2. Consider pain control 3. Remove clothing or objects in pt’s pockets 4. Locate pt’s greater trochanters 5. With the black side facing the pt; place the Sam Pelvic sling underneath the pt with

the middle of the sling at the level of the greater trochanters 6. Place the black strap through the buckle. Holding the orange strap pull the black

strap until you hear and or feel a click. Keeping the strap under tension press the black strap onto the surface of the Sam Pelvic splint

Approved by Platteville Gilcrest FPD Medical Director August 2019.

1250 PROCEDURE PROTOCOL: PATELLA RELOCATION

Indications:

● For isolated, clinically obvious, medial or lateral dislocation of the patella.

Contraindications:

● Intraarticular and superior dislocations are not reducible in the field.

● If there are other serious injuries present, this protocol does not apply.

Technique:

● Expose the site

● Check for distal pulses, movement, sensation, and circulation

● Gradually extend the knee while, at the same time, a second provider appliespressure on the patella towards the midline of the knee

● When straight, immobilize the joint above and below the knee

● Use pain management as necessary

Precautions/ Notes:

● Some increased pain may occur during reduction. Consider pain managementprior to relocation for comfort measures.

● If there is severe increased pain or resistance, stop and splint in the positionfound

● Patients usually feel significantly better after reduction, but they still needtransport to a hospital for further evaluation and possible treatment

● One attempt only

● Paramedic skill only, with EMT assist

Approved by Platteville Gilcrest FPD Medical Director February 2020

2000 OBSTRUCTED AIRWAY


No

No

EMT AEMT

EMT-I Paramedic

Attempt to determine cause of obstruction

Does patient show universal sign of choking?

• Perform Heimlich maneuver

• For visibly pregnant or obesepatients perform chest thrustsonly

Assess severity of obstruction

No

Severe or Complete Obstruction (mute, silent cough, severe stridor)

Unconscious Patient Mild or Moderate Obstruction

If obstruction is complete, patient will be mute.

If patient can speak, obstruction is incomplete

• Open airway with head tilt-chin lift orjaw thrust if craniofacial trauma

• Attempt ventilation with BVM

• Do not interfere with a spontaneouslybreathing of coughing patient

• Position of comfort

• Give high flow oxygen

• Suction if needed

Able to ventilate or obstruction cleared?

Once obstruction relieved:

• Position of comfort or left lateralrecumbent position

• O2 via NRB 15 Lpm

• Monitor ABCs, SpO2, vital signs

• Suction PRN and be preparedfor vomiting, which commonlyoccurs after obstruction relieved

Is obstruction cleared?

Yes

• Supportive care and rapidtransport

• If patient deteriorating ordevelops worsening distressproceed as for completeobstruction

• Perform laryngoscopy

• If foreign body visualized, useMcGill forceps to remove orconsider pushing object intomainstem bronchus with ETT

Able to ventilate or obstruction cleared?

Yes

Consider cricothyrotomy if suspected supraglottic obstruction

and unable to oxygenate with BVM

No

Yes

• For infants, 5 chest thrusts then 5back blows

• Perform abdominal thrusts orchest thrusts until obstructionrelieved then reattemptventilations with BVM

• For infants, 5 chest thrusts,then 5 back blows

Begin chest thrusts

Each time airway is opened look in mouth for FB and if found, remove it

Yes

2010 ADULT UNIVERSAL RESPIRATORY DISTRESS


Consider pulmonary and non-pulmonary causes of

respiratory distress:

• Pulmonary embolism

• Pneumonia

• Heart attack

• Pneumothorax

• Sepsis

• Metabolic acidosis (e.g.:DKA)

• Anxiety

Respiratory Distress

For all patients: While assessing ABCs: give

supplemental O2, monitor vital signs, cardiac rhythm, SpO2 and waveform

capnography

Patent airway? Obstructed Airway protocol

Are ventilations adequate for physiologic state?

Assist ventilations with BVM and airway adjuncts as needed

Is anaphylaxis likely? Allergy/Anaphylaxis protocol

Is asthma or COPD likely? Adult Wheezing protocol

Is CHF/pulmonary edema likely? CHF/Pulmonary Edema protocol

• Transport

• Provide supportive care

• Maximize oxygenation andventilation

• Contact Base if needed forconsult

• Consider 12 lead ECG

Mixed picture may exist

• Goal is maximization ofoxygenation and ventilationin all cases

• CPAP may be particularlyuseful in mixed picture withhypoxia and/orhypoventilation

• Avoid albuterol insuspected pulmonaryedema

?

EMT AEMT

EMT-I Paramedic

Yes

No

?

No

No

No

No

Yes

Yes

Yes

Yes

2020 PEDIATRIC UNIVERSAL RESPIRATORY DISTRESS


No

Are ventilations adequate for age?

For all patients: While assessing ABCs: give

supplemental O2, monitor vital signs, cardiac rhythm, SpO2, and consider waveform capnography

Patent Airway?

Is anaphylaxis likely?

Is there a barky cough and stridor?

Respiratory Distress

• Provide supportive care• Maximize oxygenation andventilation• CONTACT BASE if needed forconsult

Obstructed Airway protocol

Assist ventilations at age-appropriate rate with BVM and

airway adjuncts as needed

Allergy/Anaphylaxis protocol

Pediatric Stridor/Croup protocol

Consider pulmonary and non-pulmonary causes:

• Foreign body

• Croup

• Pneumonia

• Bronchiolitis

• Pulmonary embolism

• Sepsis

• Metabolic derangement

• Anxiety

EMT AEMT

EMT-I Paramedic

Age-appropriate ventilation rate in respiratory failure:

Age Breaths/min

Neonate 40

Infants 30

Children 20

Assisted ventilation rates listed do not apply to the patient in cardiac arrest

No

No

No

No

Yes

Yes

Yes

Yes

Is there wheezing? Pediatric Wheezing protocol Yes

Characteristics of Stridor:

• High-pitched, harshsound most often heardon inspiration

• Occurs with upperairway restriction

• Significant restrictionmay result in biphasicstridor (heard oninspiration andexpiration)

2030 ADULT WHEEZING


Adult Respiratory Distress Protocol and prepare for

immediate transport

Give nebulized albuterol + ipratropium

Therapeutic Goals:

• Maximize oxygenation

• Decrease work ofbreathing

• Identify cardiac ischemia(Obtain 12 lead EKG)

• Identify complications,e.g. pneumothorax

Is response to treatment adequate?

• Continue monitoring and assessment en route

• Be prepared to assist ventilations as needed

• Contact base for medical consult as needed

No

Yes

No

Presentation suggests Bronchospasm:

wheezing, prolonged expiratory phase, decreased breath sounds, accessory

muscle use, known hx of asthma/COPD

EMT may administer either MDI or nebulized

albuterol

May give continuous neb for severe respiratory distress

Give oxygen, check SpO2, waveform

capnography, & consider IV for severe

IV methylprednisolone will help resolve acute asthma exacerbation over hours,

without immediate effect. In severe exacerbations, it may

be given prehospital but should not be given for mild attacks responding well to

bronchodilators

IM epinephrine is only indicated for most severe

attacks deemed life-threatening and not

responding to inhaled bronchodilators. Use extreme caution when administering. Cardiopulmonary monitoring

is mandatory

IV magnesium may be beneficial in some patients

with severe attacks. It should not be given routinely, rather should be reserved for life-threatening asthma attacks

not responding to conventional therapy

• Reassess for pneumothorax

• Consider CPAP early, especially in COPD

• If CPAP contraindicated, ventilate with BVM,and consider advanced airway

• IV methylprednisolone

• Obtain ECG: rule out unstable rhythm, ACS

EMT AEMT

EMT-I Paramedic


Yes

Consider pulmonary and non-pulmonary causes of

respiratory distress:

Examples: pulmonary

embolism, pneumonia,

pulmonary edema,

anaphylaxis, heart attack,

pneumothorax, sepsis,

metabolic acidosis (e.g.:

DKA), Anxiety

COPD

• Correct hypoxia: do notwithhold maximumoxygen for fear of CO2

retention

• Patients with COPD areolder and havecomorbidities, includingheart disease.

• Wheezing may be apresentation ofpulmonary edema,“cardiac asthma”

• Common triggers forCOPD exacerbationsinclude: Infection,dysrhythmia (e.g.: atrialfibrillation), myocardialischemia

• COPD exacerbationsare particularlyresponsive to CPAP,which may help avoidthe need for intubationand should beconsidered early intreatment

• Consider IM epinephrine. Indicated only if noresponse to neb, CPAP and for pt in severedistress. Contraindicated if any concern formyocardial ischemia or known coronary arterydisease.

• Consider IV magnesium

2040 PEDIATRIC WHEEZING

No

Yes

No

Yes

• Assess for pneumothorax

• Assist ventilations with BVM

• Pediatric Universal RespiratoryDistress protocol

• Assess: SpO2, considerwaveform capnography, RR,lung sounds, accessory muscleuse and mental status

Age ≤ 2 years oldBronchiolitis most common

• Viral illness characterized by fever,

copious secretions and respiratory

distress typically seen November

through April

• Most important interventions are to

provide supplemental oxygen and

suction secretions adequately

• Bronchodilators and steroids do

not work

Consider the cause of wheezing before

initiating specific therapy

Initial best indicator is age. If patient ≤ 2years old, bronchiolitis is most likely. Age > 2

reactive airways disease is more likely.

• Administer oxygen to obtain

saturations > 90%

• Nasal suction

• Transport in position of comfort

• Monitor SpO2, RR, retractions,

mental status

If worsening respiratory distress

despite above therapies, re-suction

nostrils and assist ventilations with

BVM

BLS airway preferred in pediatrics

Age > 2 years old

Asthma most common

Presentation suggests asthma: wheezing, prolonged expiratory phase, decreased breath sounds, accessory muscle use, known hx of asthma or

albuterol use

EMT AEMT

EMT-I Paramedic

EMT may administer either MDI or

nebulized albuterol

May give continuous neb for severe respiratory distress

Give nebulized albuterol + ipratropium

Is response to treatment adequate

• IM epinephrine if no response toneb and severe distress

• Start IV

• IV methylprednisolone

• 20mL/kg NS bolus


• Continue monitoring and assessmenten route

• Be prepared to assist ventilations asneeded

• Contact Base for medical consult ifdeterioration

Severe exacerbation


IV methylprednisolone

Will help resolve acute asthma

exacerbation over hours, without

immediate effect. In severe

exacerbations, it may be given

prehospital but should not be given

for mild attacks responding well to

bronchodilators.

IM epinephrine

Is indicated for the most severe

attacks deemed life-threatening and

not responding to inhaled

bronchodilators.

Although bronchiolitis and

asthma are the most

common causes of

wheezing in infants and

children, respectively, you

should consider

pulmonary and non-

pulmonary causes of

respiratory distress,

especially if patient not

responding as expected to

treatment:

Examples: pneumonia,

pulmonary edema,

congenital heart disease,

anaphylaxis, pneumothorax,

sepsis, metabolic acidosis

(e.g.: DKA, toxic ingestion),

foreign body aspiration, and

croup.


2050 PEDIATRIC STRIDOR/CROUP


Pediatric Universal Respiratory Distress protocol and prepare for immediate

transport

Check SpO2, give oxygen as needed

Minimize agitation: Transport in position of comfort, interventions only as necessary

EMT AEMT

EMT-I Paramedic

Are symptoms severe and croup most likely?

• Stridor at rest or biphasic stridor

• Severe retractions

• SpO2 < 90% despite O

2

• Altered LOC

• Cyanosis

Give nebulized epinephrine

If signs of poor perfusion AND/OR hypotension for age, see Medical Shock

protocol and begin fluid resuscitation

• Continue monitoring and assessment en route

• Contact Base for repeat dose of nebulizedepinephrine and medical consult as needed

Characteristics of Croup:

• Most common cause ofstridor in children

• Child will have stridor,barky cough, and URIsymptoms of sudden, oftennocturnal onset

• Most often seen in children< 9 years old

• Agitation worsens thestridor and respiratorydistress

No

Yes

Considerations with Stridor:

• Stridor is a harsh, usuallyinspiratory sound causedby narrowing or obstructionof the upper airway

• Causes include croup,foreign body aspiration,allergic reactions, trauma,infection, mass

• Epiglottitis is exceedinglyrare. May consider in theunimmunized child.Treatment is minimizationof agitation. Airwaymanipulation is best donein the hospital.

2060 CHF/PULMONARY EDEMA


Yes

No

Yes

Universal Respiratory Distress

Protocol

Give nitroglycerin (NTG)

Therapeutic Goals:

Maximize oxygenation

Decrease work ofbreathing

Identify cardiac ischemia(Obtain 12 lead ECG)

Special Notes:

In general diuretics havelittle role in initial treatmentof acute pulmonary edemaand are no longerconsidered first linetherapy.

Morphine has beenassociated with worseoutcomes in patients withCHF and is no longerpreferred

Is oxygenation and ventilation adequate?

Continue monitoring and assessment

Transport

Contact base for medical consult asneeded

No

If failing above therapy:

Remove CPAP and ventilate withBVM

Consider pneumothorax

Consider alternativediagnoses/complications

Consider advanced airway


CHF/Pulmonary edema

Obtain 12 lead ECG: rule out unstable rhythm, STEMI

EMT AEMT

EMT-I Paramedic

Start CPAP protocol

3000 MEDICAL PULSELESS ARREST ALGORITHM

• Start CPR

• Attach manualdefibrillatorASAP

• Give O2

Shockable Rhythm?

VT/VF Asystole/PEA

• Start IV/IO

• Epinephrine

Shockable Rhythm?

Shockable Rhythm?

B

Epinephrine every 3-5 min

• Start IV/IO

• Epinephrine

Go to Box A

Shockable Rhythm?

• Epinephrineevery 3-5 min

• Amiodarone

• Treat reversiblecauses (“Hs &Ts”)

Pulseless Arrest

Check rhythm & shock if indicated.

Repeat every 2 min

Start CPR + apply AED

BLS Sequence EMT EMT-I

Paramedic

ALS Sequence

NoYes

Shock then CPR x 2 min

• If asystole, goto box B

• If organizedrhythm, checkpulse. If nopulse, go tobox B

• If ROSC, beginpost-cardiacarrest care

Yes

No

A

Yes

No

Yes

Suspected hyperkalemic arrest (renal failure/dialysis patient):

• Give IV calcium

• Give IV sodium bicarb

• Flush IV line between meds

AEMT



CPR x 2 min

Reversible Causes:

• Hypovolemia

• Hypoxia

• Hydrogen ion (acidosis)

• Hypo/hyperkalemia

• Hypothermia

• Tension pneumothorax

• Tamponade, cardiac

• Toxins

• Thrombosis (pulmonary,coronary)

Defibrillation

• EMT + AEMT use AED

• Intermediate and Paramedic usemanual defibrillator No

Mechanical CPR Devices:

• During operation of thesedevices patients may show signsof consciousness such as eye orarm movement with absent vitalsigns

• Consider administering abenzodiazepine if patientappears agitated even withabsent vital signs

• Devices generally need to onlybe stopped for ECG analysis;keep the device operating andcheck for asynchronous pulse

Approved by Platteville Gilcrest FPD Medical Director January 2020.

3010 UNIVERSAL PULSELESS ARREST CONSIDERATIONS

ADULT PATIENT

Compressions

• Follow current ACLS guidelines for chest compressions

• Minimize interruptions, resume compressions immediatelyafter shocks, rhythm checks. Check pulses only iforganized rhythm

• Push hard and fast and allow complete chest recoil

• Assess quality of CPR with continuous waveformcapnography

• If ETCO2 < 10, improve quality of compressions

• If using automated CPR devices, use manufacturer’sspecifications

Defibrillation

• Biphasic: manufacturer recommendation. If unknown, usemaximum energy

• Monophasic: 360 J

Ventilations

• Open the airway, place NPA/OPA, place NRB facemaskwith O2 at 15 L/min for first 4 minutes of chestcompressions, unless hypoxic arrest suspected (e.g.:asphyxiation, overdose, status asthmaticus), In whichcase begin ventilations immediately.

• Do not over ventilate

• If no advanced airway, 30:2 compressions to ventilationratio

• If advanced airway in place ventilate at rate of 10breaths/min

Airway

• An advanced airway (King, LMA, ETT) may be placed atany time after initial 4 minutes of passive oxygenation, ifapplicable, or as soon as possible if asphyxial arrestsuspected, provided placement does not interruptcompressions

ROSC

• Pulse and blood pressure

• Sustained abrupt rise in ETCO2, typically > 40

PEDIATRIC PATIENT

Compressions

• Follow current PALS guidelines for chest compressions

• Minimize interruptions, resume compressions immediatelyafter shocks, rhythm checks. Check pulses only iforganized rhythm

• Push hard (≥ 1/3 of anteroposterior chest diameter andfast (100-120/min) and allow complete chest recoil

• Assess quality of CPR with continuous waveformcapnography

Defibrillation:

• 1st shock 2 J/kg, subsequent shocks 4 J/kg

• EMT + AEMT use AED

• Intermediate and Paramedic use manual defibrillator

Ventilations

• If no advanced airway, alternate ventilations andcompressions in 15:2 ratio

• If advanced airway in place, ventilate continuously at 10breaths/minute

• Do not over ventilate

Airway

• No intubation for cardiac arrest < 12 years’ old

• BVM preferred for all pediatric patients

• An appropriately-sized supraglottic airway (e.g. King) maybe placed as an alternative if BVM ventilations areinadequate

ROSC

• Pulse and blood pressure

• Sustained abrupt rise in ETCO2, typically > 40

Regarding where to work arrest and presence of family members:

• CPR in a moving ambulance or pram is ineffective

• In general, work cardiac arrest on scene either to return ofspontaneous circulation (ROSC), or to fieldpronouncement, unless scene unsafe

• Family presence during resuscitation is preferred by mostfamilies, is rarely disruptive, and may help with grievingprocess for family members. Family presence duringresuscitation is recommended, unless disruptive toresuscitation efforts

• Contact base for termination of resuscitation

Pacing

• Pacing is not indicated for asystole and PEA. Instead startchest compressions according to Universal PulselessArrest Algorithm.

• Pacing should not be undertaken if it follows unsuccessfuldefibrillation of VT/VF as it will only interfere with CPR andis not effective

ICD/Pacemaker patients

• If cardiac arrest patient has an implantable cardioverterdefibrillator (ICD) or pacemaker: place pacer/defib pads atleast 1 inch from device. Biaxillary or anterior posteriorpad placement may be used


3020 N EONATAL RESUSCITATION

No

Yes

Yes

Yes

Yes

Yes

Yes

No

No

No

No

No

60 sec

30 sec

Birth Term Gestation? Breathing or crying? Good flex or tone?

Warm, clear airway if necessary, dry, simulate

HR <100, gasping or apnea

PPV, SpO2 monitoring

HR <100?

Take ventilation corrective steps

HR <60?

Chest compressions Coordinate w. PPV

100% O2

HR <60 after 60 seconds of chest compressions?

IV epinephrine

Routine Care:

• Provide warmth

• Clear airway if necessary

• Dry

• Ongoing evaluation

Labored breathing or persistent cyanosis?

Clear airway SpO

2 monitoring

Supplementary O2 as needed

Post resuscitation care

Take ventilation corrective steps

Consider:

• Hypovolemia

• Pneumothorax

EMT AEMT

EMT-I Paramedic

Targeted Preductal (Right Arm) SpO2 After Birth

(From 2015 NRP Guidelines)

• 1 minute: 60%-65%

• 3 minutes: 60%-75%

• 5 minutes: 80%-85%

• 10 minutes: 85%-95%

Neonatal Oxygen Recommendations

(From 2015 NRP Guidelines)

• Begin resuscitation ofnewborns ≥ 35 weeksgestation with room air. Ifbreathing is labored,supplement with oxygen tothe targets listed

• Begin resuscitation ofnewborns <35 weeksgestation with supplementaloxygen titrated to thetargets listed

General Considerations (From 2015 AHA Guidelines)

• Newborn infants who do not require

resuscitation can be identified generally

based on 3 questions:

• Term gestation?

• Crying or breathing?

• Good muscle tone?

• If answer to all 3 questions is “yes” then

baby does not require resuscitation and

should be dried skin-to-skin on mother

covered to keep warm

• If answer to any of 3 questions is “no then

infant should receive 1 or more of the

following 4 categories of intervention in

sequence:

• Initial steps in stabilization (warm, clear

airway, dry, stimulate)

• Ventilation

• Chest compressions

• Administration of epinephrine and/or

volume expansion

• Initial resuscitation steps should be

completed within 60 seconds as illustrated

• The decision to progress beyond initial

steps is based on an assessment of

respirations (apnea, gasping, labored, or

unlabored breathing) and heart rate

(>/< 100 bpm)

Assisting Ventilations

• Assist ventilations at a rate of 40-60

breaths per minute to maintain HR > 100

• Use 2 person BVM when possible

Chest Compressions

• Indicated for HR < 60 despite adequate

ventilation w. supplemental O2 for 30

seconds

• 2 thumbs-encircling hands technique

preferred

• Allow full chest recoil

• Coordinate with ventilations so not

delivered simultaneously

• 3:1 ratio for compressions to ventilations

Medications

• Epinephrine is indicated if the newborn’s

heart rate remains less than 60 beats/min

after at least 30 seconds of PPV AND

another 60 seconds of chest compressions

coordinated with PPV using 100% oxygen


3030 POST-RESUSCITATION CARE WITH ROSC

ROSC after cardiac arrest

Perform 12 lead EKG

Yes

No

Initiate Cardiac Alert

• Assess for shock and volume status

• Peripheral access: IO/IV

• Oxygenation/Ventilation

o Secure advanced airway if

indicated

o Avoid hyperventilation

o Avoid hyper/hypocapnia (EtCO2)

o Correct hypoxemia

• Elevate head of bed at 30°

• Continuous rhythm monitoring and

pulse checks

• Focused neuro exam (AVPU/GCS)

• Targeted Temperature Management

(TTM) goal 33° - 36° C (91.4° - 96.8°F)o Check patient temperature, if

possibleo Avoid fever and provide passive

coolingo Place ice packs to neck, axillae,

groin if needed for fever

• Transfer to closest appropriate facility

Assess for dysrhythmia

Treat recurrent

dysrhythmia per

appropriate protocol

No

Yes

No

Yes

Medical

Hypotension/Shock

protocol

Post-Cardiac Care

• Following ROSC, severalsimultaneous and stepwiseinterventions must beperformed to optimize careand maximize patientoutcome

• Survival and neurologicoutcome worsen with fever,hypoxia, hypo/hypercapnia,and hypotension. Post-ROSCcare should focus onprevention of these elements

EMT AEMT

EMT-I Paramedic

Return of spontaneous circulation (ROSC) criteria:

• Pulse and measurable bloodpressure

• Increase in ETCO2 oncapnography

Document:

• Time of arrest (or time lastseen normal)

• Witnessed vs. unwitnessedarrest

• Initial rhythm shockable vs.non-shockable

• Bystander CPR given

• Time of ROSC

• GCS after ROSC

• Initial temperature of patientafter ROSC, if possible

Recurrent dysrhythmia?

Is there hypotension for age and/or signs of shock?

Is STEMI Present?


3040 TACHYARRHYTHMIA WITH POOR PERFUSION

Yes

No

EMT AEMT

EMT-I Paramedic

Tachyarrhythmia

• Support ABCs

• IV access

• Give oxygen

• 12 lead ECG

Stable

• Identify Rhythm

• Measure QRS width

Narrow QRS Adult < 0.12 msec

Pediatric <0.09 msec

• Repeat 12 lead ECG

• Identify rhythm

• Contact Base

Is patient stable?

Unstable signs include altered mental status, chest pain, hypotension, signs of shock-rate-related symptoms

uncommon if HR <150 in adults

A Unstable

Immediate synchronized cardioversion

B

Irregular

• Atrial fibrillation, flutter, orMAT

• Do not give adenosine

• If becomes unstable go tobox B

C Irregular

• See box C• Contact Base for consult• Do NOT give adenosine

Doesn’t Convert

• Contact Base for consult

• Monitor in transport

• If unstable, go to box B

Converts

• Repeat 12 lead ECG

• Monitor in transport

• If recurrent dysrhythmia, goto box A

Regular

•

•

•

•

• Try Valsalva maneuver

• Give adenosine IV ifsuspected AV nodalreentrant tachycardia(AVRNT)*

• EMT-I requires direct orderfor adenosine

Regular

•

• V Tach (>80%) or SVT withaberrancy

• Contact Base for verbal orderfor amiodarone unlesscontraindicated

• If regular and polymorphic(Torsades de Pointes)consider magnesium

Probable Sinus Tachycardia?

• Adult: rate usually <150

• Search for and treatunderlying cause: e.g.dehydration, fever,hypoxia, hypovolemia, pain

• Consider medical shock

Wide QRSAdult > 0.12 msec

Pediatric >0.09 msec

• Contact Base for consult• Children who are stablewith AVNRT generallyremain so and transport ispreferred over intervention

• Children: rate usually <180

• Infants: rate usually < 220

• 12 lead ECG


3050 BRADYARRHYTHMIA WITH POOR PERFUSION

Bradycardia with a pulseHeart rate < 60

Are there signs or symptoms of poor perfusion present?

(Altered mental status, chest pain, hypotension, signs of shock)

Adequate perfusion Poor perfusion

Monitor and transport• Give atropine

• Prepare fortranscutaneouspacing

Monitor and transport

Reminders:

• If pulseless arrest develops, go to pulselessarrest algorithm

• Search for possible contributing factors: “5 Hsand 5 Ts”

• Symptomatic severe bradycardia is usuallyrelated to one of the following:o Ischemia (MI)o Drugs (beta blocker, Calcium channel

blocker)o Electrolytes (hyperkalemia)

• Support ABCs

• Give Oxygen

• Start IV

• Initiate transport

• Cardiac monitor

• Identify rhythm

• 12-lead ECG

Consider vasopressor infusion early if pacing and poor perfusion or hypotension persists either due to lack of capture or poor contractility despite capture

EMT AEMT

EMT-I Paramedic

Pediatric Considerations:

• Consider any HR <60 in an ill child abnormalregardless of age

• Perform CPR if HR < 60 with poor perfusiondespite oxygenation and ventilation

• Administer epinephrine if bradycardia persistsdespite oxygenation/ventilation and chestcompressions

• Atropine should be administered for increasedvagal tone or AV block

• Give epinephrine

• Consider atropine

• If no improvement,Contact Base to discusstranscutaneous pacing


3060 CHEST PAIN


EMT AEMT

EMT-I Paramedic

Consider opioid for chest pain refractory to nitroglycerin, if no contraindication

For hypotension following nitroglycerin give 250 ml NS bolus, reassess, and repeat bolus as needed. Do not give additional nitroglycerin.

Life threatening causes of chest pain:

Acute coronary syndrome (ACS)Pulmonary embolismThoracic aortic dissectionTension pneumothorax

Nitroglycerin Contraindications: Suspected right ventricular ST-segment elevation MI (inferior STEMIpattern plus ST elevation in right-sidedprecordial leads e.g. V4R)Hypotension SBP < 100Recent use of erectile dysfunction(ED) medication (e.g. Viagra, Cialis)

Consider repeat 12-lead if initial 12-lead non-diagnostic and/or patient’s condition changesConsider additional 12-lead views such as Rsided leads for R ventricular infarct if inferiorMI present

No Yes Notify receiving facility immediatelyif Cardiac Alert criteria metPlace combination defibrillation/pacing pads on patient

STEMI?

An EMT may administer patient’s prescribed nitroglycerin, Contact Base for verbal order

Give SL nitroglycerin if suspected cardiac chest pain and no contraindication

Causes of Chest Pain in Children: CostochondritisPulmonary CausesIschemia Is rare but can be seen witha history of Kawasaki’s disease withcoronary aneurysmsCyanotic or Congenital Heart DiseaseMyocarditisPericarditisArrhythmiaAnxietyAbdominal Causes

Consider life threatening causes of chest pain in all patients

While assessing ABCs titrate oxygen, monitorvital signs, cardiac rhythm, start IVObtain 12-lead ECGAdminister aspirin if history suggests possiblecardiac chest pain

Obtain 12-lead ECG

3070 CARDIAC ALERT


Goal:

To identify patients with ST-segment elevation myocardial infarction (STEMI) in the prehospitalsetting and provide advanced receiving hospital notification in order to minimize door-to-balloon times for percutaneous coronary intervention (PCI)

Inclusion Criteria:

Chest discomfort consistent with ACS12-lead ECG showing ST-segment elevation (STE) at least 1 mm in two or more anatomicallycontiguous leadsAge 35-85 years old (If STEMI patient outside age criteria, contact receiving hospital forconsult)

Exclusion Criteria:

Wide complex QRS (paced rhythm, BBB, other)Symptoms NOT suggestive of ACS (e.g.: asymptomatic patient)If unsure if patient is appropriate for Cardiac Alert, discuss with receiving hospital MD

Actions:

Treat according to chest pain protocol en route (cardiac monitor, oxygen, aspirin, nitroglycerinand opioid as needed for pain control).Notify receiving hospital ASAP with ETA and request CARDIAC ALERT. Do not delay hospitalnotification. If possible, notify ED before leaving scene.Start 2 large bore peripheral IVs – avoid the right wrist or hand if possible in the field to avoidinterfering with cath lab radial accessPlace combination defibrillation/pacing pads on patientRapid transportIf patient does not meet inclusion criteria, or has exclusion criteria, yet clinical scenario and ECG suggests true STEMI, request medical consult with receiving hospital emergencyphysician.

Additional Documentation Requirements:

Time of first patient contactTime of first ECG

EMT-I Paramedic

3080 HYPERTENSION

AEMT EMT-I Paramedic

Intent:

A. Even with extremes of blood pressure, treat the medical emergency associated withhypertension (“treat the patient, not the number”)

1. Treat chest pain, pulmonary edema, or stroke according to standard protocols(pain control will usually improve BP significantly)

B. Do not use medication to treat asymptomatic hypertensionC. Do not treat hypertension in acute strokeD. Obtain 12 lead ECG if patient presentation suggests hypertension as a possible primary

cause


3090 VENTRICULAR ASSIST DEVICES

Assess the patient

Typically, LVAD patients have no discernible pulse. Blood pressure measurement requires manual BP cuff and Doppler which the patient may have. Utilize other parameters for patient assessment:

• Level of consciousness

• Respiratory rate and work of breathing

• Signs of perfusion: skin color/temperature, capillary refill (HR >100 is hemodynamically unstable)

• Cardiac monitor, SpO2, blood glucose level

STABLE • Address any medical problems

according to protocol

• Transport to University of ColoradoHospital for further treatment, if practical

• Contact VAD Coordinator

Ventricular Assist Device (VAD)

A Ventricular Assist Device (VAD) is a mechanical device used to support circulation in a patient with significant cardiac ventricular dysfunction. The Left Ventricular Assist Device (LVAD) is commonly used to support the left side of the heart and to provide extra cardiac output to the body. This device can be placed short term to bridge patients until they can receive a heart transplant or long term for people who are not candidates for a transplant. LVAD patients can be identified by an electric driveline cable that comes directly out of their abdomen and connects to an external control pack powered by two external batteries they will be wearing with a bag, harness or vest. The patient still has underlying heart function and rhythm that can be assessed and treated as appropriate per protocols.

EMT AEMT

EMT-I Paramedic

UNSTABLE• Determine if VAD is running and

functioning properly

• Auscultate chest for whirling sounds

• Examine VAD control unit for alarms

VAD RUNNING• 250 mL bolus

• Notify destination of VAD patientinbound

• Consider chest compressions if apneicwith no clinical evidence of perfusion

• Initiate ACLS (PALS if patient pre-pubescent) and address underlyingdysrhythmia or other problems perprotocol

VAD NOT RUNNING• Consider chest compressions if required

• Address VAD alarms/faults

• Consider defibrillation if required

• Notify destination of VAD patientinbound

• Initiate ACLS (PALS if patient pre-pubescent)

Key Points

• Unstable VAD patients should be transported to the nearest appropriate facility. University of Colorado Hospital is the onlyfacility in the region that definitively treats VAD patients—and is therefore the preferred destination when patient condition isstable and conditions/operational factors allow transport.

• Contact VAD Coordinator as soon as possible at 24/7 pager # (303) 266-4522. For pediatric patients contact theChildren’s Hospital Colorado transplant coordinator pager at (303) 890-3503. Provide patient name, DOB, condition & ETAat destination for consultation and/or if transporting to University of Colorado Hospital. VAD coordinator will call back.

• VAD patient family members are excellent resources to assist with patient history and evaluation/repair of VAD alarms/faults.• It is vital to transport the patient’s back-up batteries and emergency equipment with the patient.• Device specific information for EMS can be found at: https://www.mylvad.com/medical-professionals/ems

Common VAD Complications

• CVA

• TIA

• Arrhythmias

• Infections

• Sepsis

• Obstructions

• Pump Failure

Is the patient stable?


https://www.mylvad.com/medical-professionals/ems

4000 MEDICAL SHOCK PROTOCOL

Consider etiology of shock state

Etiologies of Shock

• Dysrhythmia, myocardial ischemia

• Sepsis

• Hemorrhage

• Anaphylaxis

• Overdose

• Cyanide or carbon monoxide poisoning

• Other: PE, MI, tension pneumothorax

• ABCs

• Complete set of vital signs

• Full monitoring

• O2 via NRB facemask @ 15L/min

• IV/IO access

Treat dysrhythmia per appropriate protocol

For ongoing hypotension, poor perfusion or pulmonary edema, consider Vasopressor Infusion

If patient at risk for adrenal insufficiency, see Adrenal

Insufficiency protocol

Administer IV/IO fluids 20 mL/kg; reassess and repeat if needed

EMT AEMT EMT-I Paramedic Hypotension for age and/or signs of poor perfusion

Pediatric Fluid Administration

• For children <40 kg or not longer than length basedtape, hand pull/push fluid with a 60 mL syringeutilizing a 3 way stop cock.

• The treatment of compensated shock requiresaggressive fluid replacement of 20 mL/kg up to 3boluses.

• Goal of therapy is normalization of vital signs withinthe first hour.

• Hypotension is a late sign in pediatric shock patients.

Pediatric Shock

Signs of Compensated Shock Signs of Decompensated Shock

• Normal mental status

• Normal systolic blood pressure

• Tachycardia

• Prolonged (>2 seconds) capillary refill

• Tachypnea

• Cool and pale distalextremities

• Weak peripheral pulse

• Decrease mental status

• Weak central pulses

• Poor color

• Hypotension for age

Hypotension for Age

Age Blood Pressure

<1 year <70 mmHg

1-10 years <70 + (2 x age in years)

>10 years <90 mmHg

Tachycardia for Age

Age Heart Rate

<1 year >160 bpm

1-2 years >150 bpm

2-5 years >140 bpm

5-12 years >120 bpm

>12 years >100 bpm


4010 UNIVERSAL ALTERED MENTAL STATUS

Altered Mental Status (AMS)

Assess ABCsGo to pulseless arrest, adult respiratory distress, pediatric respiratory distress or obstructed airway

protocols as appropriate

Persistent AMS?

Check BGL and consider trial of Naloxone

BGL < 60 mg/dL or clinical condition suggests hypoglycemia?

Seizure activity present?

Perform rapid neurologic assessment including LOC and

Cincinnati Prehospital Stroke Score (CPSS)

Focal neuro deficit or positive CPSS?

Consider other causes of AMS:Head trauma, overdose, hypoxia,

hypercapnea, heat/cold emergency, sepsis, & metabolic

During transport:

• Give supplemental oxygen,monitor vital signs, airway,breathing

• Give fluid bolus if volumedepletion or sepsis suspected

• Cardiac rhythm/12 lead ECG

• Determine character of event

• Consider Seizure, Syncope, andTIA

• Monitor and transport withsupportive care

Hypoglycemia protocol

Seizure protocol

Stroke protocolDetermine time last seen normalConsider Stroke Alert criteria and

contact destination hospital

Alcohol intoxication?

Drug/Alcohol Intoxication protocol

No

Yes

Yes

No

No

Yes

Yes

No

Yes

EMT AEMT

EMT-I Paramedic

• Cardiac rhythm /12 lead ECG forunexplained altered mental status


4020 SYNCOPE

General Information:

• Syncope is defined as transient loss of consciousness accompanied by loss of postural tone.

• A syncopal episode will generally be very brief and have a rapid recovery with no postictal confusion.

• Convulsive movements called myoclonic jerks may occur with syncope. This is often confused with seizures, but shouldnot be accompanied by a post-ictal phase, incontinence or tongue biting.

• Elderly syncope has a high risk of morbidity and mortality

Universal Altered Mental Status

• Assess and stabilize ABCs, give O2 ifneeded, assess vital signs

• Rule out and treat hypoxia

• Rule out and treat hypoglycemia

• Perform and document neurologic exam

Consider etiology and treat accordingly

All patients with syncope are advised to come to the hospital for evaluation

Causes of Syncope:

• Cardiaco Structural heart diseaseo Arrhythmia (Prolonged QT,

Brugada, WPW, heartblock, etc.)

• Seizure

• Hypovolemiao Dehydrationo Blood losso Pregnancy/ectopic

• Pulmonary Embolism

• Vasovagal

EMT AEMT

EMT-I Paramedic

Pediatric Considerations:

• Life-threatening causes of pediatric syncope are usually cardiac in etiology (arrhythmia, cardiomyopathy, myocarditis,

or previously unrecognized structural lesions)

• In addition to the causes listed above, consider the following in the pediatric patient:

Seizure Heat intolerance Breath holding spells BRUE (Brief Resolved Unexplained Events,

formerly ALTE) Toxins (marijuana, opioids, cocaine, CO, etc.)

• Important historical features of pediatric syncope include: color change, seizure activity, incontinence, post-ictal state,

and events immediately prior to syncope event

• Obtain 12 lead ECG


4030 STROKE


The Cincinnati Prehospital Stroke Scale(CPSS) is designed to be very reproducible andidentify those strokes most likely to benefit fromreperfusion therapy, but does not identify allstrokes.The CPSS is highly specific for stroke, but isnot extremely sensitive, meaning if you have apositive CPSS, you are almost certainly havinga stroke, but if you do not have a positiveCPSS, you still may be having a strokeStroke signs may be very subtle, therefore it isimportant to know other signs of stroke, whichinclude:o Impaired balance or coordination o Vision loss o Headache o Confusion or altered mental status o Seizure

Rule out or treat hypoglycemia

Determine when last KNOWN to be normaland document specific time“At 2:15 PM”, not “1 hour ago”

Consider common stroke mimics/syndromes

Obtain medical history Document medications Identify family or friend who may assist withhistory and decision-making, get contactinfo and strongly encourage to come to EDas they may be needed for consent fortreatments

Fully monitor patient and continually reassess:Improvement or worsening of deficitAdequacy of ventilation and oxygenationCardiovascular stability

POSSIBLE STROKE Any acute onset neurological deficit not likely

due to trauma regardless of age

Start IV and draw bloodDocument cardiac rhythm/12 lead ECGEnsure full monitoring in place: cardiac,SpO2 Elevate head 30°, if possible

Assess and stabilize ABCs, titrate O2

Assess Cincinnati Prehospital Stroke Score (Presence of single sign sufficient)

Notify receiving hospital of suspectedstroke and time of onset of symptoms inorder to provide hospital the opportunity forStroke AlertIt is more important that you knowtimeline of your patient’s symptomsthan an individual hospital’s Stroke Alertcriteria, which may vary

Cincinnati Prehospital Stroke Scale Think “FAST” (face, arm, speech, time)

Assess Facial DroopSay: “Smile for me”, or “Show me your teeth”

Assess Arm Pronator Drift

Demonstrate, and say: “Put your arms up for me like this and hold them while I count to 10”

Assess SpeechSay: “Repeat after me: you can’t teach an old dog

new tricks”, or “No ifs, ands, or buts”

CPSS does not identify all strokes. See below

Stroke Mimics (for all ages): HypoglycemiaPost-ictal paralysisComplex migraineOverdoseTraumaBell’s palsy


Cincinnati Prehospital Stroke ScaleThink “FAST” (face, arm, speech, time)

Document cardiac rhythm/12 lead ECG Ensure full monitoring in place: cardiac,

4040 SEIZURE

Consider the Cause of Seizure

Epilepsy EtOH withdrawal or intoxication

Hypoglycemia

Stimulant use

Trauma

Intracranial hemorrhage

Overdose (TCA)

Eclampsia Infection: Meningitis, sepsis

Febrile (age < 6 years old)

Yes No

Check pulse and reassess ABC Give supplemental oxygen

No

Yes

Yes

CONTACT BASE

If seizure brief and self-limited, treatment notnecessary

Rule out hypoglycemia (check blood glucose)

If prolonged (e.g.: > 5 min) or recurrentseizure, then treat as follows:

Actively Seizing?

Transport and monitor ABCs, vital signs,and neurological condition

Cardiac monitoring if recurrent seizuresand/or meds given

Complete head to toe assessment

Support ABCs:

Give oxygen

Rule out or treat hypoglycemia

Universal seizure precautions (see below)

Consider the cause (see below)

Universal Seizure Precautions:

Ensure airway patency, but do not forceanything between teeth.

Give oxygen

Suction as needed

Protect patient from injury

Check pulse immediately after seizurestops

Keep patient on side

Document:

Document: Seizure history: onset, timeinterval, previous seizures, type ofseizure

Obtain medical history: head trauma,diabetes, substance abuse, medications,compliance with anticonvulsants,pregnancy

Pregnancy and Seizure:

If 3rd

trimester pregnancy or post-partum: administer magnesium sulfate

No

Actively seizing after 5 minutes?

Give benzodiazepine

Actively seizing after 5 minutes?

Establish IV access if notalready in place

Repeat benzodiazepine

EMT AEMT

EMT-I Paramedic


4050 HYPOGLYCEMIA


Is BGL < 60?

Check blood glucose level in ANY patient with signs or symptoms consistent with

hypoglycemia

Examples: Altered MS, agitation, focal neurologic deficit,

seizure, weakness, diaphoresis, decreased motor tone, pallor

Administer oral glucose. Reassess patient

No

Monitor and transport or contact base for refusal if

indicated

• Glucagon IM

• Alternative: Ifsevere symptoms(coma), considerIO and administerdextrose IO

Yes

Yes

If hypoglycemia still most likely despite normal

reading on glucometer, administer glucose regardless, while

considering other causes of altered mental status

Symptoms resolved?

Yes

Yes

No

Still symptomatic? Are you able to establish IV access?

Administer dextrose IV & reassess patient

Yes

No

Recheck BGL and consider other

causes of altered mental status

No

Regarding refusals after a hypoglycemic episode:

See Patient Refusal protocol

Transport is always indicated for any of the following patients:

• Pts with unexplained hypoglycemia

• Pts taking oral hypoglycemic meds

• Pts not taking food by mouth

• Pts who do not have competent adultto monitor

Can the patient safely tolerate oral glucose?

intact gag reflex, follows verbal commands

No

Considerations for Hyperglycemia:

• In general, treat the patient,not the glucose value. Treatshock if present.

• Consider NS bolus forpatients with hyperglycemiaand no evidence of fluidoverload.

• Pediatric patients withconcern for DKA should notexceed 10-20 mL/kg of fluids.


4060 PEDIATRIC BRIEF RESOLVED UNEXPLAINED EVENTS (BRUE) (FORMERLY ALTE)

DEFINITION: An infant < 1 year of age with episode frightening to the

observer characterized by apnea, choking/gagging, color change or change in muscle tone

Obtain detailed history of event and medical history

Complete head-to-toe assessment

Support ABCs as necessary

Any child with an BRUE should betransported to ED for evaluation

Monitor vital signs en route

Clinical history to obtain from observer of event:

Document observer’s impression of the infant’s color, respirations and muscle tone

For example, was the child apneic, or cyanotic or limp during event?

Was there seizure-like activity noted?

Was any resuscitation attempted or required, or did event resolve spontaneously?

How long did the event last?

Past Medical History:

Recent trauma, infection (e.g. fever, cough)

History of GERD

History of Congenital Heart Disease

History of Seizures

Medication history

Examination/Assessment

Head to toe exam for trauma, bruising, or skin lesions

Check anterior fontanelle: is it bulging, flat or sunken?

Pupillary exam

Respiratory exam for rate, pattern, work of breathing and lung sounds

Cardiovascular exam for murmurs and symmetry of brachial and femoral pulses

Neuro exam for level of consciousness, responsiveness and any focal weakness

EMT AEMT

EMT-I Paramedic


4070 DRUG/ALCOHOL INTOXICATION

BGL < 60 mg/dL or clinical condition suggests hypoglycemia?

Hypoglycemia protocol

Does patient have evidence of incapacitating

intoxication?

Transport to ED

DEFINITIONS:

Intoxicated patient with any of the following must be transported to ED:

Incapacitating Intoxication

• Inability to maintain airway

• Inability to stand from seated position andwalk with minimal assistance

• At immediate risk of environmentalexposure or trauma due to unsafe location

Acute Illness or Injury

• Abnormal vital signs

• Physical complaints that might indicate anunderlying medical emergency, e.g.: chestpain

• Seizure or hypoglycemia

• Signs of trauma or history of acute trauma

• Signs of head injury, e.g.: bruising,lacerations, abrasions

No

No

Yes

Yes

Does patient have signs of acute illness or

injury?

Transport to ED

No

Contact base if considering release to other party, e.g.: police, family

(IMPORTANT: individual agency policy may apply)

Clinical intoxication

Always consider alternative diagnoses: see universal altered

mental status protocol

Yes

Bystander Administered Naloxone:

• Refer to naloxone protocol regardingbystander administered naloxone andpatient refusal.

*

*


Determine LOC and assess ABCs

• Obtain vital signs

• Perform head-to-toe exam

• Determine medical history, medications

• Check BGL unless mild symptoms. Ifconsidering release, must check BGL.


4080 OVERDOSE AND ACUTE POISONING

See Seizure protocol

See Agitated/ Combative

Patient protocol

PPE and decontaminate when appropriate

Obtain specific information:

Type of ingestion(s)

What, when and how much ingested?

Bring the poison, container, all medication and otherquestionable substances to the ED

Note actions taken by bystanders or patient (e.g.: inducedemesis, “antidotes”, etc)

Supportive Care is key to overdose management

ABCsIV, oxygen, monitor

Consider Naloxone

Universal Altered Mental Status protocol

IV fluid bolus per Medical Shock protocol

Stimulant

Tachycardia, HTN, agitation,

sweating, psychosis

Tricyclic antidepressant

Wide complex tachycardia,

seizure

Organophosphate or nerve agent

DUMBELS syndrome

Calcium Channel Blocker

Bradycardia, heart block, hypotension

ß-Blocker

Bradycardia, heart block, hypotension

Benzodiazepine for severe symptoms

Sodium Bicarbonate for QRS > 100 msec

If intubated, consider hyperventilation to

ETCO2 25-30 mmHg

Atropine

Fluids per Medical Shock Protocol

Vasopressor Infusion

Fluids per Medical Shock Protocol

Yes

No

Yes

No

Yes Check BGL

Consider specific ingestions

No

Need for airway management?

Hypotension for age?

Altered mental status?

Specific ingestion?

Glucagon

(AEMT, EMT-I requires verbal order)

See Adult or Pediatric Respiratory Distress protocols

Glucagon

(AEMT, EMT-I requires verbal order)

Nerve Agent Antidote Kit

Calcium and Vasopressor Infusion

for hypotension

EMT AEMT

EMT-I Paramedic


If oral ingestion, call poison control1-800-222-1222

4090 ALLERGY AND ANAPHYLAXIS

• Start IV

• Give diphenhydramine

• Give methylprednisolone

Generalized or Systemic ReactionMultisystem involvement: skin, mucus

membranes, and gastrointestinal symptoms

Airway involvement?Tongue or uvula swelling, stridor

Transport and reassess for signs of deterioration

Consider diphenhydramine if

significant discomfort

Allergic reaction, anaphylaxis or angioedema

• Assess ABCs, give oxygen

• If possible, determine likely trigger

• Determine PMH, medications, allergies

• Classify based on symptom severity andsystems involved

• Other specific protocols may apply: e.g.:obstructed airway, bites & envenomation

Does patient have any of the following signs or symptoms? • Hypotension

• Signs of poor perfusion

• Bronchospasm, stridor

• Altered mental status

• Give epinephrine IM, then:

• Start IV and give IV bolusper medical shock protocol



• Consider addition ofalbuterol if wheezing

• Monitor ABCs, SpO2,cardiac rhythm

• Reassess for signs ofdeterioration

Localized ReactionIncluding isolated tongue, airway

Give immediate IM epinephrine & manage airway per Obstructed

Airway Protocol

If persistent signs of severe shock with hypotension not

responsive to IM epinephrine and fluid bolus:

• Contact Base

• Consider IV epinephrine dripper vasopressor infusionprotocol

No

Yes

No

Definitions:

• Anaphylaxis: severe allergic reaction that is rapid in onset and potentially life-threatening. Multisystem signs and symptoms are present including skin andmucus membranes

o Mainstay of treatment is epinephrine

• Angioedema: deep mucosal edema causing swelling of mucus membranesof upper airway. May accompany hives

o Mainstay of treatment is methylprednisolone. Epinephrineindicated for any impending airway obstruction.

Document:

• History of allergen exposure, prior allergic reaction and severity, medicationsor treatments administered prior to EMS assessment

• Specific symptoms and signs presented: itching, wheezing, respiratorydistress, nausea, weakness, rash, anxiety, swelling of face, lips, tongue,throat, chest tightness, etc.

EMT AEMT

EMT-I Paramedic





Yes

4100 NON-TRAUMATIC ABDOMINAL PAIN/VOMITING

Non-traumatic abdominal pain and/or vomiting

Assess ABCs

Give oxygen

Complete set of vital signs

Consider life-threatening causes

If signs of poor perfusion AND/OR hypotension for age, see Medical Shock

protocol and begin fluid resuscitation

Consider IV

If GI bleed, start 2nd IV

Transport in position of comfort

Consider antiemetic for vomiting

Consider opioid for severe pain

Cardiac monitor and 12 lead ECG for any of the following:

Diabetic

Age > 50

Upper abdominal pain concerning forACS

Unstable vital signs in the adult patient

Monitor and transport

Frequent reassessment fordeterioration and response totreatment

Life-threatening causes:

Cardiac etiology: MI, ischemia

Vascular etiology: AAA, dissection

GI bleed

Gynecologic etiology: ectopicpregnancy

History:

Onset, location, duration, radiation ofpain

Associated sx: vomiting, biliousemesis, GU sx, hematemesis, coffeeground emesis, melena, rectalbleeding, vaginal bleeding, known orsuspected pregnancy, recent trauma

Pediatric Patients:

Life-threatening causes vary by age.Consider occult or non-accidentaltrauma, toxic ingestion, button batteryingestion, GI bleed, peritonitis

For most pediatric patients withoutsigns of shock, no IV is required andpharmacologic pain managementshould be limited

Elderly Patients:

Much more likely to have life-threatening cause of symptoms

Shock may be occult, with absenttachycardia in setting of severehypovolemia



4110 SUSPECTED CARBON MONOXIDE EXPOSURE

COHb Severity Signs and Symptoms

<15-20% Mild Headache, nausea, vomiting, dizziness, blurred vision

21-40% Moderate Confusion, syncope, chest pain, dyspnea, tachycardia, tachypnea, weakness

41-59% Severe Dysrhythmias, hypotension, cardiac ischemia, palpitations, respiratory arrest, pulmonary edema, seizures, coma, cardiac arrest

>60% Fatal Death

ABCs

100% FIO2

and transport

Symptoms of CO

or hypoxia

Measure COHb%

(SpCO)

SpCO 0-5%

General Guidelines:

• Signs and Symptoms of COexposure include:

Headache, dizziness, coma,

altered mentation, seizures,

visual changes, chest pain,

tachycardia, arrhythmias,

dyspnea, N/V, “flu-like illness”

• The absence or low readings of

COHb is not a reliable predictor

of toxicity of other fire byproducts

• In smoke inhalation victims,

consider cyanide treatment with

Hydroxocobalamin as per

indications

• The fetus of a pregnant woman

is at higher risk due to the

greater affinity of fetal

hemoglobin to CO. With CO

exposure, the pregnant woman

may be asymptomatic while the

fetus may be in distress. In

general, pregnant patients

exposed to CO should be

transported.

SpCO > 15%SpCO 5-15%

No further

evaluation of

SpCO is

needed

Contact Base

for consult

100% FIO2

and transport

Yes

No

EMT AEMT

EMT-I Paramedic


4120 ADRENAL INSUFFICIENCY PROTOCOL

Give corticosteroid

Patient at risk for adrenal insufficiency

(Addisonian crisis):

• Identified by family or medical alert bracelet

• Chronic steroid use

• Congenital Adrenal Hyperplasia

• Addison’s disease

• Chronic corticosteroid use is a common causefor adrenal crisis, carefully assess for steroid usein patients with unexplained shock.

• Administration of steroids are life-saving andnecessary for reversing shock or preventingcardiovascular collapse

• Patients at risk for adrenal insufficiency mayshow signs of shock when under physiologicstress which would not lead to cardiovascularcollapse in normal patients. Such triggers mayinclude trauma, dehydration, infection,myocardial ischemia, etc.

• If no corticosteroid is available during transport,notify receiving hospital of need for immediatecorticosteroid upon arrival

• Under Chapter 2 Rule: specialized prescriptionmedications to address an acute crisis may begiven by all levels with a direct VO, given theroute of administration is within the scope of theprovider. This applies to giving hydrocortisone foradrenal crisis, for instance, if a patient or familymember has this medication available on scene.Contact base for direct verbal order

• Continue to monitor for development ofhypoglycemia

• Contact base for consult if patient notresponding to treatment

All symptomatic patients:

• Check blood glucose and treathypoglycemia, if present

• Start IV and give oxygen

• If signs of poor perfusion AND/ORhypotension for age, see Medical Shockprotocol and begin fluid resuscitation

Assess for signs of acute adrenal crisis:

• Pallor, weakness, lethargy

• Vomiting, abdominal pain

• Hypotension, shock

• Congestive heart failure

• Monitor 12 lead ECG for signs ofhyperkalemia

EMT AEMT

EMT-I Paramedic


4130 EPISTAXIS MANAGEMENT

ABCs

General Guidelines:

Most nose bleeding is from an

anterior source and may be easily

controlled.

Avoid phenylephrine in pts with

known CAD.

Anticoagulation with aspirin,

clopidogrel (Plavix), warfarin

(Coumadin) will make epistaxis

much harder to control. Note if

your patient is taking these, or

other, anticoagulant medications.

Posterior epistaxis is a true

emergency and may require

advanced ED techniques such as

balloon tamponade or

interventional radiology. Do not

delay transport. Be prepared for

potential airway issues.

For patients on home oxygen via

nasal cannula, place the cannula

in the patient’s mouth while nares

are clamped or compressed for

nosebleed.

Active nosebleed

Tilt head forward

Have patient blow

nose to expel clots

Spray both nares with

phenylephrine

Compress nostrils

with clamp or fingers,

pinching over fleshy

part of nose, not bony

nasal bridge

Transport in position

of comfort, usually

sitting upright

IV access and IV fluid

bolus if signs of

hypoperfusion, shock

EMT AEMT

EMT-I Paramedic


4140 SEPSIS PROTOCOL


Yes

Yes

Evaluate potential SIRS Criteria: Temp < 36C (96.8F) or > 38C (100.4F)HR > 90 (or tachycardic for age)RR > 20 or mechanical ventilation (ortachypneic for age)

Principles of Sepsis Multiple studies demonstrate the benefit of early recognitionand treatment of sepsis, including in the prehospital setting.Early hospital notification of sepsis may lead to shorter timeto IV fluid and IV antibiotics and increase survival.Patients with septic shock require aggressive IV fluidresuscitation. Starting dose should be 30mL/kg of IV fluid.EtCO2 has been demonstrated to correlate with serumlactate levels and predictive of severity of sepsis. Asustained EtCO2 <25 mmHg may indicate hypoperfusion.Some agencies may carry lactate monitors. In that case, alactate level of 4 mmol/L is indicative of hypoperfusion.

ABCs Complete set of vital signs Monitoring including SpO2 andwaveform capnographyO2 as appropriate

Is there evidence of hypoperfusion? (ANY ONE OF THE FOLLOWING):

IV fluid bolus @ 30mL/kg (if no sign offluid overload)2 large bore IV’sTransport to closest appropriate hospital

EMT AEMT EMT-I Paramedic Evaluate and identify potential sepsis – is

there suspected or confirmed infection?

For ongoing hypotension, poor perfusion or pulmonary edema, consider Vasopressor

Infusion (adult patients only)

Routine CareIV, O2, monitorConsider fluid bolus if sepsis suspectedTransport to closest appropriate hospitalContinue to re-assess vital signs andperfusion

NOTIFY HOSPITAL of potential sepsis (hospital activation criteria may vary)

Hypotension forageAltered mentalstatus (excludingsimple febrileseizure) Delayed capillaryrefill AND mottling

Are there two or more SIRS criteria?

Pediatric Fluid Administration For children <40 kg or not longer than length-basedtape, hand pull/push fluid with a 60 mL syringeutilizing a 3 way stop cock.The treatment of compensated shock requiresaggressive fluid replacement, may need to repeatfluid bolus up to 60mL/kg.Goal of therapy is normalization of vital signs withinthe first hour.Hypotension is a late sign in pediatric shock patients.

Systolic BP < 90mmHgMAP <65 mmHgSustained EtCO2<25 mmHg

No

No

Common Infection Sites with Severe Sepsis

Respiratory Bacteremia (unspecified site) Genitourinary (more prevalentwith females)Abdominal Device-related Soft tissue/wound Central nervous system Endocarditis

5000 DROWNING


Remove wet garments, dry andinsulate patientSuction as neededStart IV, obtain BGL, give oxygenTransportMonitor ABC, VS, mental status

Specific Information Needed: Length of submersion Degree of contamination ofwater Water temperature Diving accident and/or suspected trauma

Spinal precautions before moving patient if trauma

suspected

Monitor cardiac rhythm

Remove wet garments, dryand insulate patientTransport, even if initialassessment normalMonitor ABC, VS, mentalstatus If respiratory distressdevelops, consider CPAP asdelayed pulmonary edema may occur af ter drowning.

Remove wet garments, dry and insulatepatientHeimlich maneuver NOT indicatedConsider all causes of Altered Mental StatusSuction as neededStart IV, obtain BGL and give oxygenMonitor ABC, VS, mental status, waveformcapnography

ABCs

Assess mental status

Awake but altered LOC Comatose or unresponsive

Yes No

Drowning/submersion commonly associated with hypothermia.Even profound bradycardias may be suf f icient in setting of severe hypothermia and decreased O2 demandGood outcomes af ter even prolonged hypothermic arrest are possible, therefore patients with suspected hypothermia should generally be transported to the hospital.BLS: pulse and respirations may be very slow and dif f icult to detect if patient is severely hypothermic. If no def inite pulse,and no signs of life, begin CPR If not breathing, start rescue breathingALS: advanced airway and resuscitation medications are indicated

Consider advanced airway especially ifsuspected pulmonary edemaMonitor cardiac rhythm

Pulse Present?

EMT AEMT

EMT-I Paramedic

and insulate

Awake and alert


Start CPR with manual ventilationsAttach AED/monitor/def ibrillator Single def ibrillation attempt only if hypothermicTreat per Medical Arrest Algorithm withfollowing changes if hypothermic:o Handle very gentlyo Start IV with warm IV f luido Insulate patiento For asystole, v-f ib, or pulseless v-tach,

single dose epinephrine IV/IO

Consider advanced airway especially ifsuspected pulmonary edemaMonitor cardiac rhythm, waveformcapnography


5010 HYPOTHERMIA


Remove wet garments, dry andinsulate patientSuction as neededStart IV, check BGL, give oxygenTransportMonitor ABC, VS, mental status

Monitor cardiac rhythm

Remove wet garments, dry and insulatepatientConsider all causes of Altered Mental StatusSuction as neededStart IV, obtain BGL and give oxygenTransportMonitor ABC, VS, mental status, waveformcapnography

Awake but altered LOC Comatose or unresponsive

Yes No


Pulse Present?

EMT AEMT

EMT-I Paramedic

Hypothermia and Frostbite

Remove wet garments, dry and insulate patient Transport, even if initialassessment normalMonitor ABC, VS, mental statusDress injured area lightly in clean cloth to protect f rom further injuryDo not rub, do not break blistersDo not allow injured part toref reeze. Repeated thaw f reezecycles are especially harmfulMonitor for signs of systemichypothermia

Localized cold injury Frostbite, frostnip

Even profound bradycardias may be suf f icient in setting of severe hypothermia and decreased O2 demandGood outcomes af ter even prolonged hypothermic arrest are possible, therefore patients with suspected hypothermia should generally be transported to the hospital.BLS: pulse and respirations may be very slow and dif f icult to detect if patient is severely hypothermic. If no def inite pulse, and no signs of life, begin CPR If not breathing, start rescue breathingALS: advanced airway and resuscitation medications are indicated

Systemic hypothermia Presumed to be primary problem

based on clinical scenario

High f low O2 ABCs


Start CPR Attach AED/monitor/def ibrillator Single def ibrillation attempt onlyTreat per Medical Arrest Algorithm withfollowing changes:o Handle very gentlyo Start IV with warm IV f luido Insulate patiento For asystole, v-f ib, or pulseless v-tach,

single dose epinephrine IV/IO



5020 HYPERTHERMIA


Heat Cramps Normal or slightly elevated bodytemperature Warm, moist skin Generalized weakness Diffuse muscle cramping

Heat Exhaustion

Elevated body temperatureCool, diaphoretic skinGeneralized weaknessAnxietyHeadacheTachypneaPossible syncope

Heat Stroke

Altered mental statusVery high core body temperatureHot, dry skinHypotensionSeizureComa

Rapid transport indicated

Adequate airway and breathing?

No Yes

Assist ventilations and manage airway

as needed

Remove excess clothing For heat stroke, consider externalcooling measures if prolongedtransportTreat seizures, cardiac arrhythmiasper protocolMonitor and transport

General Guidelines:

People can sweat through heat stroke right upuntil they die depending on their level of acclimatization. Heat stroke has mortality that exceeds trauma,STEMI, and Stroke and should be treatedaccordingly

Other causes of hyperthermia besides environment exposure:

Neurolopeptic malignant syndrome (NMS):patients taking antipsychotic medications Sympathomimetic overdose: cocaine,methamphetamine Anticholingergic toxidrome: overdose (“Madas a hatter, hot as a hare, blind as a bat, redas a beet”) common w. ODs on psych meds,OTC cold medications, Benadryl, Jimsonweed, etc. Infection: fever (sepsis) Thyrotoxicosis: goiter (enlarged thyroid)

Administer IV/IO fluids 20 mL/kg up to 1 L of cool saline; reassess and

repeat if needed

Monitor VS and transport

Hyperthermia Classify by clinical syndromeConsider non-environmentalcauses (see below)

EMT AEMT

EMT-I Paramedic

Administer O2

Administer IV/IO fluids 20 mL/kg up to 1 L of cool saline; reassess and repeat

if needed

5030 HIGH ALTITUDE ILLNESS

Acute mountain sickness (AMS): headache, insomnia,

anorexia, nausea, fatigue

High-altitude pulmonary edema (HAPE): dyspnea, cough, headache, nausea, fever

High-altitude cerebral edema (HACE): ataxia, confusion, neuro

deficits, seizure, coma, and headache

Symptoms of illness at altitude

ABCs

IV, oxygen

Cardiac monitor

AMS

O2 NRB facemask

Consider CPAP

Assist ventilations as needed

Airway management as indicated

Do NOT give diuretic

Descent from altitude

O2 NRB facemask

Assist ventilations as needed

Airway management as indicated

Elevate head of bed

HACE is rare at elevations in Colorado; always consider alternative cause of altered

mental status

Head to toe assessment

Complete history:

Rate of ascent, prior altitudeillness, rapidity of sx onset

Consider non-altitude-related illness

Never assume that symptoms ataltitude are necessary due to altitudeillness.

Acute exacerbations of chronicmedical illness at altitude are morecommon that altitude illness.

Consider antiemetic for vomiting

If signs of poor perfusion AND/OR hypotension for age, see Medical

Shock protocol and begin fluid resuscitation

EMT AEMT

EMT-I Paramedic

HAPE HACE

Special Notes:

There are no specific factors that accurately predict susceptibility to altitude sickness, but symptoms are worsened by exertion,

dehydration, and alcohol ingestion.

Acute Mountain Sickness (AMS) can begin to appear at around 6,500 ft above sea level, although most people will tolerate up to

8000 ft without difficulty. Altitude illness should not be suspected below 6,500 ft. AMS is the most frequent type of altitude

sickness encountered. Symptoms often manifest themselves six to ten hours after ascent and generally subside in one to two

days, but they occasionally develop into the more serious conditions.

High altitude pulmonary edema (HAPE) and cerebral edema (HACE) are the most severe forms of high altitude illness. The rate

of ascent, altitude attained, exertion, and individual susceptibility are contributing factors to the onset and severity of high-altitude

illness

Mild HAPE may be managed with high-flow oxygen and supportive care, and does not necessarily require descent from altitude.

More severe forms of HAPE and all forms of HACE require descent


5040 INSECT/ARACHNID STINGS AND BITES PROTOCOL


Initiate general care for bites and stings

Assess for localized vs. systemic signs and symptoms

and depending on animal involved

Localized Symptoms:

• Pain, warmth andswelling

Consider opioid for severe pain (e.g.: black widow spider) and /or diphenhydramine if needed for itching

Systemic Symptoms:

• Hives, generalizederythema, swelling,angioedema

• Hypotension • Altered mental status• Other signs of shock

• Administer oxygen

• Start IV

Treat per allergy & anaphylaxis protocol

Specific Precautions:

• For all types of bites and stings, the goal of prehospital care is to prevent further envenomation and to treat allergicreactions

• Anaphylactoid reactions may occur upon first exposure to allergen, and do not require prior sensitization

• Anaphylactic reactions typically occur abruptly, and rarely > 60 minutes after exposure

General Care

• For bees/wasps:o Remove stinger mechanism by

scraping with a straight edge. Donot squeeze venom sac

• For spiders:o Bring in spider if captured or dead

for identification

Specific Information Needed:

• Timing of bite/sting

• Identification of spider, bee, wasp,other insect, if possible

• History of prior allergic reactions tosimilar exposures

• Treatment prior to EMS eval: e.g.EpiPen, diphenhydramine, etc


diphenhydramine if needed for itching

5050 SNAKE BITE PROTOCOL


Obtain specific information:

Appearance of snake (rattle, color, thermalpit, elliptical pupils)

Appearance of wound: location, # of fangsvs. entire jaw imprint

Timing of bite

Prior 1st aid

To help with identification of snake,photograph snake, if possible. Includeimage of head, tail, and any distinctivemarkings.

Do not bring snake to ED

• Assess ABCs, mental status

• Administer oxygen

• Start IV Fluids at TKO rate• Monitor VS

General Care:

Remove patient from proximity to snake

Remove all constricting items from bittenlimb (e.g.: rings, jewelry, watch, etc.)

Immobilize bitten part

Initiate prompt transport

Do NOT use ice, refrigerants, tourniquets,scalpels or suction devices

Mark margins of erythema and/or edemawith pen or marker and include timemeasured

Assess for localized vs. systemic signs and symptoms

Localized Symptoms:

Pain and swelling

Numbness, tingling tobitten part

Bruising/eccymoses

Systemic Symptoms:

Metallic or peculiartaste in mouth

Hypotension

Altered mental status

Widespread bleeding

Other signs of shock

Be prepared to manage airway if signs of airway

obstruction develop

If there is hypotension for age and/or definite signs of shock, treat per Shock

Protocol

Initiate general care for snake bites

Transport with bittenpart immobilized

Monitor ABCs and fordevelopment ofsystemic signs/sx

Complete General Careen route

Specific Precautions:

The prairie rattlesnake is native to Denver Metro region and is most common venomous snake bite in the region.

Exotic venomous snakes, such as pets or zoo animals, may have different signs and symptoms than those of pitvipers. In case of exotic snake bite, contact base and consult zoo staff or poison center for direction.

Take a picture of the snake, including images of head and tail. If an adequate photo can be taken, it is notnecessary to bring snake to ED.

Never pick up a presumed-to-be-dead snake by hand. Rather, use a shovel or stick. A dead snake may reflexively biteand envenomate.

> 25% of snake bites are “dry bites”, without envenomations.

Conversely, initial appearance of bite may be deceiving as to severity of envenomation.

Fang marks are characteristic of pit viper bites (e.g. rattlesnakes).

Jaw prints, without fang marks, are more characteristic of non-venomous species.

Opioid for severe pain and if not contraindicated

by hypotension

Opioid for severe pain


6000 PSYCHIATRIC/BEHAVIORAL PATIENT PROTOCOL


Scene Safety A. Scene safety and provider safety are a priority. Consider police contact if

scene safety is a concern.B. Refer to restraint protocol as needed, especially as it relates to A.

Specific Information Needed A. Obtain history of current event; inquire about recent crisis, toxic exposure,

drugs, alcohol, emotional trauma, and suicidal or homicidal ideation.B. Obtain past history; inquire about previous psychiatric and medical problems, medications.

Specific Objective Findings A. Evaluate general appearance

1. E.g.: Well groomed, disheveled, debilitated, bizarrely dressedB. Evaluate vital signs.

1. Is a particular toxidrome suggested, e.g.: symphathomimetic?C. Note medic alert tags, breath odors suggesting intoxication.D. Determine ability to relate to reality.

1. Does the patient know who s/he is, where s/he is, who you are and why you are there?2. Does the patient appear to be hallucinating or responding to internal stimuli?

E. Note behavior. Consider known predictors of violence:1. Is the patient male, intoxicated, paranoid or displaying aggressive or threatening behavior or

language?Treatment

A. If patient agitated or combative, see Agitated/Combative Patient protocolB. Attempt to establish rapportC. Assess ABCsD. Transport to closest appropriate Emergency DepartmentE. Be alert for possible elopementF. Consider organic causes of abnormal behavior (trauma, overdose, intoxication, hypoglycemia)G. If patient restraint considered necessary for patient or EMS safety, refer to restraint protocol.H. Check blood sugarI. If altered mental status or unstable vital signs:

1. Administer oxygen.2. Establish venous access.3. Refer to Universal Altered Mental Status protocol.

Transporting Patients Who Have a Psychiatric Complaint

A. If a patient has an isolated mental health complaint (e.g. suicidality), and does not have a medical complaint or need specific medical intervention, then that patient may be appropriately transported by law enforcement according to their protocols.

B. If a patient has a psychiatric complaint with associated illness or injury (e.g. overdose, altered mental status, chest pain, etc), then the patient should be transported by EMS

C. Reasonable concern for suicidal or homicidal ideation, or grave disability from psychiatric decompensation, is sufficient to assume that the patient may lack medical decision-making capacity to refuse ambulance transport. Effort should be made to obtain consent for transport from the patient, and to preserve the patient’s dignity throughout the process. However, the patient may be transported over his or her objections and treated under implied consent if patient does not comply.

D. A patient being transported for psychiatric evaluation may be transported to any appropriate receiving emergency department.

E. Accusations of kidnapping or assault of the patient are only theoretical and rarely occur. The Platteville-Gilcrest FPD Medical Director feels strongly that the risk of abandonment of a potentially suicidal or otherwise gravely impaired patient is far greater. Be sure to document your reason for taking the patient over their objections, that you believe that you are acting in the patient's best interests and be sure to consult a BASE PHYSICIAN if there are concerns.

EMT AEMT

EMT-I Paramedic

6000 PSYCHIATRIC/BEHAVIORAL PATIENT PROTOCOL

Specific Precautions

A. Patients presenting with psychiatric decompensation often have an organic etiology. Be suspicious forhypoglycemia, hypoxia, head injury, intoxication, or toxic ingestion.

B. Providers transporting a patient over his or her objections should reassure the patient. The providershould strongly consider whether the patient may need restraint and/or sedation for safety. Beware ofweapons. These patients can become combative.

Transporting Patients on a Mental Health Hold

A. By law, patients detained on a mental health hold may not refuse transport. Similarly, by law, patients ona mental health hold are required to be evaluated by a physician or psychologist and must be transported.

B. Although it is commonly believed that the original copy of the mental health hold (form M-1) is required toaccompany the patient, a legible copy of the M-1 is also sufficient if the original cannot be found.

C. The M-1 form documenting the mental health hold should be as complete as possible, including thecorrect date and time that the patient was detained. The narrative portion should be completed. Asignature and license or badge number is also required. Assure that the form is complete beforedeparting.

D. The mental health hold does not need to be started on patients who are intoxicated on drugs and/oralcohol. Nor is it required for patients who are physically incapable of eloping from care, such as thosewho are intubated, or physically unable.

E. The patient rights form (M-2) does not need to accompany the patient. The receiving facility maycomplete this form if there are concerns.

F. If possible, seek direction from the sending facility regarding whether the patient may require sedationand restraint. Consider ALS transport if this is the case.

G. Recall that patients who are a danger to self/others or gravely disabled due to mental illness may betransported by EMS without a mental health hold, under implied consent.


6010 AGITATED/COMBATIVE PATIENT PROTOCOL


Assume the patient has a medical cause of agitation and treat

reversible causes

Still significantly agitated?

Patient is agitated and a danger to self or others

• Attempt to reasonably addresspatient concerns

• Assemble personnel

Patient does not respond to verbal de-escalation techniques

Restraint Protocol Obtain IV access as soon

as may be safely accomplished

Sedate

• Consider cause ofagitation

• Options:benzodiazepine orbutyrophenone

Still significantly agitated?

• Repeat sedation dose

• If still significantlyagitated 5 minutesafter 2nd dosesedative, ContactBase

Consider Cause of Agitation:

Both benzodiazepines and butyrophenones (e.g. haloperidol) are acceptable options for agitated

patients. In certain clinical scenarios individual medications

may be preferred

• EtOH (butyrophenone)

• Sympathomimetic (benzo)

• Psych (butyrophenone)

• Head injury (butyrophenone)

Does patient have signs of the Excited Delirium Syndrome?

No

Yes

General Guideline:

Emphasis should be placed on scene safety, appropriate use of restraints and

aggressive treatment of the patient’s agitation.

Excited Delirium Syndrome

These patients are truly out of control and have a life-threatening medical emergency they will have

some or all of the following sx:

Paranoia, disorientation, hyper-aggression, hallucination,

tachycardia, increased strength, hyperthermia

• Give benzodiazepine

• Up to a total of 3 doses may begiven as a standing order. Goalis rapid tranquilization in order tominimize time struggling

• Reassess ABCs post sedation

• High flow O2

• Start 2 large bore IVs as soonas may be safely accomplished

• Administer 2 liters NS bolus

Start external cooling measures

Full cardiac, SpO2, waveform capnography monitoring and rapid

transport

Restraints No transport in hobble or

prone position. Do not inhibit patient breathing, ventilations

• Complete Restraint Protocol


6020 TRANSPORT OF THE HANDCUFFED PATIENT

Purpose:

1. Guideline for transport of patients in handcuffs placed by law enforcement

Guideline:

1. Handcuffs are only to be placed by law enforcement. EMS personnel are not permittedto use handcuffs.

2. Request that law enforcement remain with the patient in the ambulance, if possible. If notpossible, request that police ride behind ambulance so as to be readily available toremove handcuffs if needed in an emergency situation to facilitate medical care of thepatient.

3. EMS personnel are not responsible for the law enforcement hold on these patients.4. Handcuffed patients will not be placed in the prone position.5. Handcuffs may be used with spinal immobilization. Medical priorities should take priority

in the positioning of the handcuffs.


7000 CHILDBIRTH PROTOCOL

Overview:

EMS providers called to apossible prehospital childbirthshould determine if there isenough time to transportexpectant mother to hospital or ifdelivery is imminent

If imminent, stay on scene andimmediately prepare to assistwith the delivery


Obtain obstetrical history (see adjacent)

ABCs O2 15 liters via NRB

IV access

Specific Information Needed:

Obstetrical history:o Number of pregnancies (gravida)o Live births (PARA)o Expected delivery dateo Length of previous laborso Narcotic use in past 4 hours

If suspected imminent childbirth:

Allow patient to remainin position of comfort

Visualize perineum

Determine if there istime to transport

Imminent Delivery

Delivery is imminent if there is crowning or bulging of perineum

Emergency Childbirth Procedure

If there is a prolapsed umbilical cord or apparent breech presentation, go toobstetrical complications protocol and initiate immediate transport

For otherwise uncomplicated delivery:

Position mother supine on flat surface, if possible

Do not attempt to impair or delay delivery

Support and control delivery of head as it emerges

Protect perineum with gentle hand pressure

Check for cord around neck, gently remove from around neck, if present

Suction mouth, then nose of infant as soon as head is delivered

If delivery not progressing, baby is “stuck”, see obstetrical complicationsprotocol and begin immediate transport

As shoulders emerge, gently guide head and neck downward to deliver anteriorshoulder. Support and gently lift head and neck to deliver posterior shoulder

Rest of infant should deliver with passive participation – get a firm hold on baby

Keep newborn at level of mother’s vagina until cord stops pulsating and isdouble clamped

Delivery not imminent

Transport in position of comfort, preferably on leftside to patient’s requested hospital if time andconditions allow

Monitor for progression to imminent delivery

Postpartum Care Infant

Suction mouth and nose only if signs of obstruction bysecretions

Respirations should begin within 15 seconds afterstimulating reflexes. If not, begin artificial ventilations at 30-40 breaths/min

If apneic, cyanotic or HR < 100, begin neonatalresuscitation

Dry baby and wrap in warm blanket

After umbilical cord stops pulsating, double clamp 6” frominfant abdominal wall and cut between clamps with sterilescalpel. If no sterile cutting instrument available, lay infanton mother’s abdomen and do not cut clamped cord

Document 1 and 5 minute APGAR scores

Postpartum Care Mother

Placenta should deliver in 20-30 minutes. If delivered,collect in plastic bag and bring to hospital. Do not pull cordto facilitate placenta delivery and do not delay transportawaiting placenta delivery

If the perineum is torn and bleeding, apply direct pressurewith sanitary pads

Postpartum hemorrhage – see obstetrical complicationsprotocol

Initiate transport once delivery of child is complete andmother can tolerate movement

Critical Thinking:

Normal pregnancy is accompanied byhigher heart rates and lower bloodpressures

Shock will be manifested by signs ofpoor perfusion

Labor can take 8-12 hours, but aslittle as 5 minutes if high PARA

The higher the PARA, the shorter thelabor is likely to be

High risk factors include: no prenatalcare, drug use, teenage pregnancy,DM, htn, cardiac disease, prior breechor C section, preeclampsia, twins

Note color of amniotic fluid formeconium staining


7010 OBSTETRICAL COMPLICATIONS


Complications of Late Pregnancy

3rd Trimester Bleeding (6-8 months)

High flow O2 via NRB, IV access

Suspect placental abruption or placenta previa

Initiate rapid transport

Position patient on left side

Note type and amount of bleeding

IV NS bolus for significant bleeding or shock

Eclampsia/Toxemia

High flow O2 via NRB, IV access

SBP > 140, DBP > 90, peripheral edema,headache, seizure

Transport position of comfort

Treat seizures with Magnesium Sulfate

See seizure protocol

Prolapsed Umbilical Cord

Discourage pushing by mother

Position mother in Trendelenberg or supine with hipselevated

Place gloved hand in mother’s vagina and elevate thepresenting fetal part off of cord until relieved by physician

Feel for cord pulsations

Keep exposed cord moist and warm

Breech Delivery

Never attempt to pull infant from vagina by legs

IF legs are delivered gently elevate trunk and legs to aiddelivery of head

Head should deliver in 30 seconds. If not, reach 2 fingersinto vagina to locate infant’s mouth. Press vaginal wallaway from baby’s mouth to access an airway

Apply gentle abdominal pressure to uterine fundus

IF infant delivered see childbirth protocol – Postpartum careof infant and mother

Shoulder Dystocia

Support baby’s head

Suction oral and nasal passages

DO NOT pull on head

May facilitate delivery by placing mother withbuttocks just off the end of bed, flex her thighsupward and gentle open hand pressure abovethe pubic bone

IF infant delivered see childbirth protocol –Postpartum care of infant and mother

Postpartum Hemorrhage

Massage abdomen (uterine fundus) until firm

Initiate rapid transport

Note type and amount of bleeding

Treat signs of shock with IV fluid boluses

For All Patients with obstetrical complications

Do not delay: immediate rapid transport

Give high-flow oxygen

Start IV en route if time and conditions allow. Treat signs of shock w. IV fluid boluses per Medical Hypotension/ShockProtocol

Possible actions for specific complications (below)

The following actions may not be feasible in every case, nor may every obstetrical complication by anticipated oreffectively managed in the field. These should be considered “best advice” for rare, difficult scenarios. In every case,initiate immediate transport to definite care at hospital


8000 GENERAL TRAUMA CARE

EMT AEMT

EMT-I Paramedic

• BSI

• Scene safety

• Consider mechanism

• Consider need for additional resources

• Give high flow oxygen

• Assist ventilations and manage airway asindicated

• Spinal immobilization if indicated

• IV access

Control Exsanguinating Hemorrhage:

• Apply direct pressure

• Pack wounds with hemostatic agent orroller gauze as available

• Tourniquet protocol if indicated

Assess Disability and Limitation:

• Brief neuro assessment

• Extremity splinting if indicated

If unstable see Traumatic Shock Protocol

• General impression

• ABCs and LOC

• Rapid Trauma Assessment

• Pelvic stabilization if suspected unstablepelvis based on physical exam

• Prepare for immediate transport

• SAMPLE history

• Rapid transport to appropriate TraumaCenter

• Consider pain management


8010 SPECIAL TRAUMA SCENARIOS PROTOCOLCoordinate transport destination with law enforcement

Sexual Assault Abuse/neglect

Confine history to pertinent medical needs

Provide same-sexprovider if possible

Respect patient’semotional needs

Protect evidence: No washing or changing

clothes

Coordinate transport destination with law

enforcement

Observe pt’s behavior around caregivers

Watch out for:

Injury inconsistent withstated mechanism

Delayed treatment

Spreading blame

Conflicting stories

Prior/ healing injuries

Don’t judge, accuse or confront victim

Don’t judge, accuse or confront victim or

suspected assailant

Transport patient if suspected abuse or

neglect, no matter how apparently minor the

injury

See General Trauma Care protocol

EMT AEMT

EMT-I Paramedic

Report to law enforcement or per agency guidelines (See General Guidelines Mandatory Reporting)

Mandatory Reporters:

EMS providers provide a criticallayer of protection to vulnerableadults and children who havebeen abused.

C.R.S. 19-3-304 passed in 2014extends the role of mandatedreporters to EMS providers inColorado

Mandated reporters are to“register their suspicion” ofabuse. This is not considered adirect accusation

- Informing providers at thereceiving facility of suspicions forDOES NOT meet therequirements of a mandatedreporter - EMS providers AREREQUIRED to register theirsuspicion with the appropriateauthorities


https://advance.lexis.com/api/document/collection/statutes-legislation/id/5PC1-83D0-004D-1152-00008-00?cite=C.R.S.%2019-3-304&context=1000516

8020 TRAUMA IN PREGNANCY

Avoid supine position:o Place in left lateral recumbent

position if possibleo If immobilized tilt backboard 15

to 30 degrees to the left side

EMT

Paramedic EMT-I See General Trauma Care protocol

Pregnant Trauma

(EGA > 20 weeks)

Interpret VS with caution. Pregnant patient has:

Increased heart rate

Decreased blood pressure

Increased blood volume

Estimated Gestational Age (EGA)

If EGA > 20 weeks, consider two patients: mother and fetus. Estimation of gestational age may be

made based on fundal height by palpating for top of uterus:

If uterus is at umbilicus then EGA > 20 weeks

Estimation by Last Menstrual Period: Due Date = LMP + 9 months + 7 days

EGA = current date - date of last menstrual period If available, utilize pregnancy wheel to determine

EGA.

Pregnant Trauma

(EGA < 20 weeks)

Priority is mother.

Transport all patients.

Assure hospital is aware ofpregnancy and EGA

Patients with any thoracic, abdominal, or pelvic complaint or injury may require prolonged fetal monitoring in hospital,

even if asymptomatic at time of evaluation, and even for seemingly

minor mechanism

Priority is mother.

Transport all patients withany thoracic, abdominal,pelvic injury or complaint.

AEMT


8030 TRAUMATIC PULSELESS ARREST


Yes

Blunt Trauma Penetrating Trauma

Contact Base for Consideration of

Field Pronouncement

Are there obvious signs of death OR the presence of non-survivable injuries?

(SEE BELOW)

Non-survivable Injuries

• Decapitation

• 90% 3º burns

Document:

• General impression

• Mechanism: blunt vs.penetrating

• Time and duration of arrest

• Were vital signs present at anytime?

No

Witnessed arrest? (Were signs of life observed by

EMS at any point?)

Contact Base for consideration of Field Pronouncement

Unwitnessed Witnessed

Consider MOI

(isolated GSW to head treated similar to blunt trauma)

• Consider Field Pronouncement ifsuspected arrest time > 10 minutes and nosigns of life or no response to BLS care

• Rapid transport to appropriate traumacenter.

• Identify and treat reversible life threatso Control Exsanguinating Hemorrhageo Advanced airwayo Bilateral needle chest decompression if

any trauma to trunk

o 2 IVs preferred IV NS bolus 20 mL/kgup to 1 L (IO if no IV access)

o Hypothermia prevention

• Initiate BLS CPR and ventilations at age-appropriate rate

• Consider pelvic stabilization

• Pull/push for pediatrics

o Bilateral needle chest decompression if any trauma to trunk

• Pull/push for pediatric fluid administration


8040 TRAUMATIC SHOCK


For trauma patients with hypotension for age or signs of shock:

• Initiate rapid transport to appropriatetrauma center.

• Treat and stabilize in route tohospital.

Identify and treat reversible causes of shock:

• Control exsanguinating hemorrhage.

• Treat suspected tensionpneumothorax with needledecompression.

• Apply pelvic compression device forsuspected unstable pelvic fracture.

IV Fluid Resuscitation

• Use IV fluid sparingly.

• Titrate small boluses of crystalloid topresence of peripheral pulses.

• However, hypotension is particularlyharmful to patients with severe TBI.In patients with TBI, more aggressivefluid resuscitation is justified tomaintain a normal blood pressure

Complete General Trauma Care

• Correct hypoxia and manage theairway if needed.

• Keep patient warm.

Pediatric Fluid Administration

• For children <40 kg or not longer than length-based tape,hand pull/push fluid with a 60 mL syringe utilizing a 3 waystop cock

• Hypotension is a late sign in pediatric shock patients

Pediatric Shock

Signs of Compensated Shock

Signs of Decompensated Shock

• Normal mental status

• Normal systolic bloodpressure

• Tachycardia

• Prolonged (>2 seconds)capillary refill

• Tachypnea

• Cool and pale distalextremities

• Weak peripheral pulse

• Decrease mental status

• Weak central pulses

• Poor color

• Hypotension for age

Shock is defined as impaired tissue perfusion and may be manifested by any of the following:

• Altered mental status

• Tachycardia

• Poor skin perfusion

• Low blood pressure

Traditional signs of shock may be absent early in the process, therefore, maintain a high index of suspicion and be vigilant for subtle signs of poor perfusion

Do not use Trendelenburg’s position routinely to treat hypotension. It is unnecessary and may impair respirations and/or aggravate injuries. Supine position preferred

Hypotension for Age

Age Blood Pressure

<1 year <70 mmHg

1-10 years <70 + (2 x age in years)

>10 years <90 mmHg

Tachycardia for Age

Age Heart Rate

<1 year >160 bpm

1-2 years >150 bpm

2-5 years >140 bpm

5-12 years >120 bpm

>12 years >100 bpm

Minimum Blood Pressure with TBI

Age MAP (mmHg) Minimum SBP

(mmHg)

0-23 months 50-70 75

2-5 years 60-80 80

6-8 years 65-85 85

9-12 years 70-95 90

>12 years ≥80 ≥110


• Treat suspected tensionpneumothorax with needledecompression.

• Most pediatric trauma mortality isfrom TBI, therefore fluid resuscitationto normal BP is recommended

• Use push/pull technique toadminister IV fluid boluses in children

8050 AMPUTATIONS

Control with direct pressure to

bleeding area or vessel

Complete Amputation

Apply tourniquet if bleeding not

controlled with direct pressure

Large bore IV

If hypotensive for age, treat per

Traumatic Shock Protocol

Document neurovascular exam

Amputated part:

Wrap in moist, sterile dressing

Place in sealed plastic bag

Place bag in ice water

Do not freeze part

Stump:

Cover with moist sterile dressing coveredby dry dressing

Partial Amputation:

Cover with moist sterile dressing

Splint near-amputated part in anatomic

position

Treat severe pain with opioid as needed

Cover with moist sterile

dressing

Splint near-amputated part

in anatomic position

General Trauma Care

Protocol

Partial Amputation

Monitor and transport to appropriateTrauma Center

Treat other injuries per protocol

EMT AEMT

EMT-I Paramedic

Apply tourniquet without

delay

Life-threatening bleeding

Non-Life-threatening

bleeding


EMT

EMT-IV AEMT

EMT-I Paramedic

8055 CRUSH INJURIES

Apply tourniquet to crushed extremity prior to release if entrapment has been > 2 hrs

General Trauma Care Protocol

• Consider 1-2 large bore IVs or IO

• Administer 20 mg/kg bolus Normal Saline

Entrapment greater than 2 hours?

- Manage severe pain as needed per protocolNote: Fentanyl is preferred due to lack of

vasodilation properties

- If peaked T waves, widening QRS or Loss of P wavenoted

- OR if hemodynamically unstable- OR Asystole / PEA / VT / VF

o Administer Albuterol 10mg (in 12mL)continuous to a max of 20mg

o Calcium Gluconate or Calcium Chloride 1gm IV/IO, slow bolus over 2-3 minutes. If arrhythmia or EKG changes still present after 5 minutes, contact medical control for a possible second dose.

- Administer sodium bicarbonate 50mEq IV/IOimmediately prior to release

- If cardiac changes present, contact medical control

• Monitor and transport to appropriateTrauma Center

• Treat other injuries per protocol

Special Considerations

• Contact medical control early and often

• Monitor the involved extremities for ischemia using the six P’s (Pain, Pallor, Pulselessness,Paralysis, Paresthesia, Poikilothermia [if the limb feels cooler than the temperature of theenvironment])

• Do NOT use lactated Ringer’s IV solution

• If entrapment is > 2 hours, ensure that pt has received 2 L of normal saline prior to release of entrapment

No Yes


8060 HEAD TRAUMA PROTOCOL

Yes


General Trauma Care protocol

GCS < 8 or comatose?

No

Support ventilations & maintain ETCO2

35-45 mmHg

Assess for hypotension and/or signs of shock and treat per

Traumatic Shock protocol en route

• Correct hypoxia

• Treat hypotension

• Decrease ICP by elevating head

30° if possible. Use reverseTrendelenburg if spinalprecautions needed

• Complete Rapid TraumaAssessment en route to hospital


Open airway and assist ventilations

Glasgow Coma Score (GCS) (Minimum 3, Maximum 15)

Eyes: 1. Does not open eyes2. Opens eyes to pain3. Opens eyes to voice4. Opens eyes

spontaneously

Verbal: 1. No sounds2. Incomprehensible sounds3. Inappropriate words4. Confused, disoriented5. Oriented

Motor: 1. No movement2. Extension to painful stimuli3. Flexion to painful stimuli4. Withdrawal to painful

stimuli5. Localizes to painful stimuli6. Obeys commands

Consider advanced airway if adequate ventilation and oxygenation cannot be achieved with basic airway maneuvers

• Monitor cardiac rhythm

Monitor:

• ABCs, VS, mental status, ETCO2

• Rapid transport to appropriatetrauma center

Pediatric GCS (Minimum 3, Maximum 15)

Eyes: 1. Does not open eyes2. Opens eyes to pain3. Opens eyes to voice4. Opens eyes

spontaneously

Verbal: 1. No vocal response2. Inconsolable, agitated3. Inconsistently consolable,

moaning.4. Cries but consolable,

inappropriate interactions.5. Smiles, oriented to

sounds, follows objects,interacts

Motor: 1. No motor response.2. Extension to pain.3. Flexion to pain.4. Withdrawal from pain5. Localizes pain.6. Obeys Commands.



8070 FACE AND NECK TRAUMA

EMT AEMT EMT-I Paramedic General Trauma Care Protocol

Clear airway

Rapid trauma assessment

Spinal Precautions Protocol

Assess for need for airway management

Laryngeal trauma*

Severe airway Bleeding?

Complete neuro exam

Assess for subcutaneous air

Cover/protect eyes as indicated

Do not try to block drainage from ears,nose

Save avulsed teeth in saline-soaked gauze,do not scrub clean

Transport ASAP to appropriate TraumaCenter

IV access en route

Treat other injuries per protocol

Suction airway as needed

Direct pressure if appropriate

Consider opioid for pain control as needed

Monitor ABCs, VS, mental status, SpO2,

ETCO2

Avoid intubation if patient can be oxygenated by less invasive means

Spinal precautions not routinely indicated for penetrating neck injury

Penetrating injury is very rarely associated with unstable spinal column

*Suspect laryngeal trauma with:

Laryngeal tenderness, swelling,bruising

Voice changes

Respiratory distress

Stridor

Consider advanced airway if adequate ventilation and oxygenation cannot be achieved with basic airway maneuvers


Regarding Nasal Intubation:

Contraindicated in pediatrics

Relatively contraindicated with mid-face trauma.

Avoid if mid-face grossly unstable

Yes

Yes

No

No


8080 SPINAL TRAUMA

Signs of Spinal Cord Injury:

• Sensory loss, weakness and/or paralysis

• Typically bilateral, but may beasymmetrical

• Sensory changes typically have a level,corresponding to the level of the injury

• Numbness, tingling or painful burning inarms, legs

• Central cord syndrome is an incompletespinal cord injury and causes painfulburning or sensory changed in shouldersand upper extremities bilaterally andspares the lower extremities. It may besubtle

EMT AEMT

EMT-I Paramedic

• Full spinal precautions if any neurological signsand symptoms consistent with a spine injury arepresent

• Document neuro assessments before and afterimmobilization

• Complete patient assessment


• Monitor for status changes

Large bore IV and consider 2nd line

Rapid transport to appropriate Trauma Center

General Trauma Care protocol

If hypotension and/or signs of shock, resuscitate per Traumatic Shock protocol

Spinal Immobilization not routinely indicated for penetrating neck injury

Penetrating injury is very rarely associated with unstable spinal column

Monitor ABCs, VS, mental status, SpO2, waveform capnography

Consider opioid for pain control

Patient with signs of traumatic acute spinal cord injury


8090 SPINAL PRECAUTIONS PROTOCOL


Does patient have/complain of any of the following:

• Midline C/T/L spine tenderness on palpation

• Neurologic complaints or deficits

• Other injuries which are potentially distracting

• Alteration in mentation or under influence ofdrugs or EtOH

• Barrier to evaluate for spinal injury (e.g.language or developmental barrier)

Transport patient in a position of comfort on gurney with

cervical collar

Yes

Yes

Notes:

• Backboards have not been shown to beany benefit for spinal injuries, and maycause harm.

• Backboards/scoops are useful tools forcarrying non-ambulatory patients to agurney. Patients who do not need abackboard should be gently slid off ofbackboard/scoop onto gurney.

• Self-extrication from a vehicle withassistance is likely better than standardextrication procedures.

• Vacuum mattresses should be usedpreferentially over a backboard if readilyavailable.

• Use caution when assessing for spinalinjury in elderly patients, who are at muchhigher risk and may have minimalsymptoms.

• Consider improvised cervical spineimmobilization such as towel rolls andtape or a SAM splint if needed to preventairway compromise or worsening spinalinjury if the rigid cervical collar cannot becorrectly sized to the patient

• Neurological exam documentation isMANDATORY in patients with potentialspinal trauma, including serial exams.

• Cervical collar is not indicated in isolatedpenetrating trauma

• Full spinal immobilization includesbackboard, scoop, vacuum splint, oragency approved device

Yes

Place c-collar on patient

and ask them to not move

neck

No

If NONE of above criteria, and you think patient is not

likely to have a spinal injury, no spinal

precauations required

Is the patient able to comfortably lay still and

comply with instructions?

No

Is the patient ambulatory on scene at time of EMS

arrival?

No

Is there an objective neurological deficit?

Yes

No

Full spinal immobilization


8090a.: Splinting Spinal Motion Restriction

Initial Patient Assessment • GSC 15• No Spine Tenderness or Anatomic Deformity• No Neurologic Complaints or Findings

(Numbness or Motor Weakness)• No Distracting Injuries• No Intoxication• Reliable Patient• No Language Barrier• No Limitation of Neck Movement

Pass Fail

High Risk Criteria • Long Fall (Adult >20 Feet Child > 10 Feet or 2-3 x’s Child’s

Height• Ejection from Automobile• Death in Same Passenger Compartment• Vehicle Intrusion > 12 inches at Patient Site or > 18 inches

any site• Motorcycle Crash > 20mph• Auto vs. Pedestrian/Bicyclist (Thrown, Run Over, or with

Significant Impact) • Axial Loading/Diving Injuries• Sudden Acceleration/Deceleration• Violent Impact• Motor Vehicle Crash Speed > 55mph

Restrict the Spinal Motion of the Patient

Other Considerations • Penetrating Trauma to the Head,

Neck or Torso w/out evidence ofspinal injury does not need a collar orbackboard.

• Patients with Focal NeurologicComplaints or Deficits Secondary toPenetrating Trauma may have a C-Collar placed at the paramedic’sdiscretion.

• Patients with global deficits(secondary to penetrating trauma), c-collar and backboard are notindicated.

No

Consider Spinal Clearance Protocol

Yes

Restrict the Spinal Motion of the Patient


8100 SUSPECTED SPINAL INJURY WITH PROTECTIVE ATHLETIC EQUIPMENT IN PLACE

EMT Paramedic EMT-I

Are helmet and pads in place?

Is airway accessible with helmet in place?

Immobilize/Transport with helmet and pads

in place

Are helmet and pads properly fitted and snug?

Yes

Is facemask removable in timely manner?

Remove helmet and pads prior to transport

No

Yes

No

Suspected Spinal Injury

Overview

Do not remove helmet or shoulder pads prior to EMS transport unless they are interfering with the management of acute life threatening injuries.

The helmet and pads should be considered one unit. Therefore, if one is removed, then the other should be removed as well so as to assure neutral spine alignment.

All athletic equipment is not the same. Athletic Trainers on scene should be familiar with equipment in use and be able to remove facemask prior to, or immediately upon, EMS arrival.

Standard immobilization techniques

Yes

Yes

Yes

No

No

AEMT

Do helmet and pads allow for neutral

alignment of spine?

Yes

No


8110 CHEST TRAUMA

No

• General Trauma Careprotocol

• Rapid transport to TraumaCenter

Penetrating trauma?For open sucking chest wounds -

3 sided occlusive dressing or agency approved device

Rapid transport & stabilize in

route

Large bore IV

consider 2nd

line

Yes

No

No

Yes

Flail Chest?

Are you able to oxygenate and ventilate effectively?

No

Yes

Splint with bulky dressing

Yes

Consider advanced airway if adequate

ventilation and oxygenation cannot be

achieved with basic airway maneuvers

Consider tension pneumothorax and Chest Needle Decompression

Tension pneumothorax should be suspected with presence of the following:

• Unilateral absent breath sounds AND: JVD, hypotension,difficult/unable to ventilate

• Needle decompression is NEVER indicated for simplepneumothorax

Treat per Traumatic Shock protocol in route


Monitor ABCs, VS, mental status, SpO

2, ETCO

2


Assess need for assisted

ventilations




8120 ABDOMINAL TRAUMA

IV access

Consider 2nd

line if MOI significant

Penetrating trauma?Cover wounds, viscera with saline

moistened gauze dressing

Do not attempt to repack exposed viscera

Resuscitate per Traumatic Shock protocol

Documentation

MOI

Time of injury

Initial GCS

Penetrating trauma

Weapon/projectile/trajectory

Blunt vehicular trauma

Condition of vehicle

Speed

Ejection

Airbag deployment

Restraints, helmets

Yes

No

No

Yes

Monitor ABCs, VS, mental status, SpO

2, ETCO

2


General Trauma Careprotocol

Rapid transport to TraumaCenter




8130 BURNS

Yes

Evaluate degree and body surface are involved

• General Trauma Care protocol

• Rapid transport to Trauma CenterEMT AEMT EMT-I Paramedic

Stop burning process:

• Remove clothes if not adhered to patient’sskin

• Flood with water only if flames/ smolderingpresent

Respiratory Distress hoarseness or

stridor?

• O2 NRB 15 Lpm

• Manage airway and assistventilations as indicated

• Consider CO, CN

Critical Burn*? • Start 2 large-bore IVs

• Fluids per ABA recommendations(chart below)**

IV NS TKO

• Remove rings, jewelry, constricting items

• Dress burns with dry sterile dressings


• Cover patient to keep warm


Monitor ABCs, VS, mental status, SpO2, waveform capnography

** ABA Recommended Prehospital Fluid Therapy 14 and older 500 mL/hr NS or LR 5 - 13 years 250 mL/hr NS or LR Younger than 5 125 mL/hr D5W, NS or LR If no signs of clinical hypovolemia or shock, large volume of IV fluid not needed. For typical 30 minute prehospital time, give 250 mL bolus for patient age ≥ 14.

Document:

• Type and degree of burn(s)

• % BSA

• Respiratory status including any voicechanges (hoarseness)

• Singed nares, soot in mouth

• SpO2

• PMH

• Confined space (assume CO)

*Critical Burn:

• 2º > 30% BSA

• 3º > 10% BSA

• Respiratory injury, facial burn

• Associated injuries, electrical or deepchemical burns, underlying PMH(cardiac, DM), age < 10 or > 50 yrs.

Types of Burns:

• Thermal: remove from environment, putout fire

• Chemical: brush off or dilute chemical.Consider HAZMAT

• Electrical: make sure victim is de-energized and suspect internal injuries

• Assume CO if enclosed space

• Consider cyanide poisoning (CN) ifunconscious or pulseless arrest

Designated Regional Burn Centers

Consider direct transport of isolated burns if time and conditions allow

• Children’s Hospital Colorado:Age ≤ 14

• University of Colorado Hospital:Age ≥ 15

• Swedish Medical Center: Any age

Yes

No

No


8140: Three Minute Protocol

Indication:

Penetrating Trauma: • Head. Neck. Chest. Abdomen. Pelvis.

With the above specific findings the following should occur: • Early notification of the emergency department.• Emergency transport to the appropriate facility.• Helicopter utilization with ground transport times that exceed 15 minutes.

Note: Maximum of 3 minutes on scene, unless Documented Extenuating Circumstances


8150: Trauma Team Activation

Full Trauma Team Activation Criteria:

Full Trauma Team Criteria Persons who sustain injury with any of the following:

PRIMARY SURVEY: PHYSIOLOGIC Adult: (15+ years)

Child: (0 to 15 years) In Blue Airway: Unable to adequately ventilate.

Intubated or assisted ventilations.

Respiratory rate < 10 or > 30 / minute.

Breathing: Any sign of respiratory insufficiency. Any sign of hypoxia. Accessory muscle use or grunting respirations.

Circulation: Systolic BP < 90 mm/Hg Any sign of abnormal perfusion. Capillary refill > 2 seconds or BP low for age.

Age SBP (mm/Hg)

< 1 year. < 60 mm/Hg

1 to 10 years. < 70 mm/Hg + 2x age.

>10 years < 90 mm/Hg

Deficit: Glascow Motor Scale Score ≤ 5.

AVPU: Response to pain or Unresponsive • Deterioration of a previously stable patient.• Transfers requiring blood transfusion.

SECONDARY SURVEY: ANATOMIC

Penetrating injuries to the head, neck, torso, or extremities proximal to the elbow or knee. Open or depressed skull fracture. Paralysis or suspected spinal cord injury. Flail chest. Unstable pelvic fracture. Amputation proximal to the wrist or ankle. Two or more proximal long bone fractures. (Humerus or Femur) Crushed, de-gloved, or mangled extremity.


8150: Trauma Team Activation

Limited Trauma Team Activation Criteria:

Limited Trauma Team Criteria Persons who sustain injury with any of the following:

MECHANISM OF INJURY

• Falls: (Adult) > 20 feet.

• Falls: (Child) > 10 feet or 2-3 x’s patient height.

• High Risk Automobile Crash:

• Intrusion into vehicle > 12 inches into the occupant compartment or 18 inches on the other side.

• Ejection: (Partial or Complete) from the automobile.

• Death in the same passenger compartment.

• Automobile versus Pedestrian / Cyclist. Thrown, run over, or with significant impact. (> 20 mph)

• Motorcycle Crash > 20 mph.

• High Energy Dissipation or Rapid Decelerating Incidents:

• Ejection from a motorcycle, ATV, animal, etc.

• Striking fixed object with momentum.

• Blast or explosion.

• High Energy Electrical Injury.

• Burns > 10% Total Body Surface Area (2° or 3°) and / or Inhalation Injury.

• Anti - coagulation or Bleeding Disorders with multi system injuries (Single level falls with isolated head injuries =“Anticoagulation Alert”, not limited trauma).

• Suspected Non - Accidental Trauma.

• EMS Provider Judgment.

NOTE: Must Document Rational For EMS Provider Judgment


8160 - Triage Destination Protocol

Triage Destination Protocol:

NCRETAC Pre-Hospital Trauma Algorithm

Step 1 - Respiratory Ground Transport Air Transport

• Unable to adequately ventilate Yes à

Transport to most rapidly accessible trauma center for advanced airway control

Transport to highest level trauma center unless otherwise indicated.

No â

Step 2 - Physiology Ground & Air Transport

Child (Age 0-12) or < 5 feet height Adult

Yes à

ADULTS: Transport to most rapidly accessible highest level trauma center within 15 minutes additional transport time.

CHILDREN: Transport to regional Pediatric Trauma Center unless more than 15 minutes additional transport time, then transport to most rapidly accessible highest level facility.

• Intubation (or)• Respiratory Distress (or)• Cap Refill > 2 sec (or)• B/P abnormal for age• [ <70 + 2 x age ] (or)• GCS Motor Score ≤ 5

• Intubation (or)• Systolic BP < 90 (or)• Resp Rate <10 or >29

with distress (or) • GCS Motor Score ≤ 5

No â

Step 3 - Anatomy (Any one of the below) Ground & Air Transport

• Penetrating injuries – head, neck, torso, pelvis• Flail Chest• Bilateral femur fractures• Unstable pelvis or suspected pelvic fracture• Paralysis or evidence of spinal cord injury• Amputation above the wrist or ankle• Significant Burns (Using American Burn• Association Criteria for transfer to a Burn Unit)• Un-reactive or unequal pupils

Yes à

ADULTS: Transport to most rapidly accessible highest level trauma center within 15 minutes additional transport time.

CHILDREN: Transport to regional Pediatric Trauma Center unless more than 15 minutes additional transport time, then transport to most rapidly accessible highest level facility.

BURNS: Transport to regional Burn Center unless more than 15 minutes additional transport time then most rapidly accessible highest level facility.

No â

Step 4 - Mechanism (Any one of the below) Ground Transport Air Transport

• Ejection from motor vehicle / conveyance. • High energy dissipation• Extrication > 20 min with injury • Falls > 15 adults; 2x height of child or elderly with suspected

rib fracture. • Pedestrian, motorcyclist or pedal cyclist thrown >15 feet

or run over. • Unrestrained occupant in vehicle roll over• Death of same car occupant• Significant Assault• Exposure to blast or explosion• Significant crush injury.• Intrusion of vehicle of ≥ 12” in occupant compartment • Suspected non-accidental trauma

Yes à

Transport to most rapidly accessible trauma center

Transport to Level I or II trauma center unless otherwise indicated.


8160 - Triage Destination Protocol

Triage Destination Protocol Continued:

Continued from Page 1 No â

Step 5 - Co-morbidity Considerations (Any of the below) Ground Transport Air Transport

• Extremes of ages: <5 & > 55 years of age • Extreme heat or cold• Medical Illness (such as COPD, CHF, renal failure,diabetes,

etc.) • Presence of intoxicants• Pregnancy• EMT clinical suspicion of occult injury

Yes à

Transport to any trauma center. Transport to Level I or II trauma center unless otherwise indicated.

No â

STEP 6 – None of the above apply Ground Transport Air Transport

Transport to the most rapidly accessible trauma center. Yes à

Transport to any appropriate trauma center.

Transport to any appropriate trauma center.

Note: This algorithm may be modified in multiple casualty events.



9000 GENERAL GUIDELINES: MEDICATION ADMINISTRATION

Purpose

A. Provide guidance to EMS providers in the principles of administration, delivery, and safety of approvedmedications

General Principles

A. The appropriate procedure for safe medication administration includes:1. Verification of the “Six Rights” of medication administration (right patient, right drug, right dose,

right route, right time, right documentation)2. Medication administration cross-check with practice partner verifying the Six Rights prior to drug

administration. This should include verbal repeat-back of the order by the practice partner.3. Obtain repeat vital signs after any intervention.

B. The risk of dosing error is high in children, and we recommend the use of a standardized system todecrease the rate of error. This can include age-based, weight-based, or length-based systems that hasstandardize precalculated volume-based medication dosing and equipment. These should be utilized onevery pediatric patient to guide medication dosing and equipment size.

C. Optional routes of medication administration are vast, and appropriateness given the clinical situation should be considered. Specific considerations include:

1. Intranasal (IN) administration often results in more rapid resolution or improvement in symptomscompared to IV or intramuscular (IM) administration

2. IM drug absorption and onset of action is often the slowest, as vascular absorption from fat tissueis prolonged

D. Ideally, expired medications should never be utilized for patient care. However, the nation is increasinglyfaced with the challenge of critical or potentially life-saving medication shortages. As such, the DenverMetro EMS Medical Directors have issued guidelines for the appropriate response to a nationalmedication crisis. Approved medications required for potentially emergent conditions and for which noreasonable substitution is available may be used after the posted expiration date with the followingrestrictions:

1. Medication should be approved for use by the agency’s EMS Medical Director.2. Expired medications will be used only after the supply of non-expired medications have been

exhausted3. Standard medication storage, inspection and delivery practices should be maintained

E. EMS agencies should work to establish a system of Just Culture. This is an approach to work place safetythat assumes humans, despite their best intentions to do the right thing, will make errors. Change andcare improvement does not happen without accurate, honest reporting of error. A report of error shouldbe treated with respect and examination of root cause, and not punitive action

http://www.dmemsmd.org/

9005 MEDICATIONS


ACETAMINOPHEN (TYLENOL)

Description Acetaminophen elevates the pain threshold and readjusts hypothalamic temperature-regulatory center.

Onset & Duration

• Onset: 20 minutes

• Duration: 4 hours

Indications

• Mild pain

Contraindications

• Known hypersensitivity

• Known or suspected chronic liver disease

Adverse Reactions

• Acetaminophen has a wide therapeutic window. Recommended maximum therapeutic doses areless than half the toxic dose.o Single toxic dose in a 70 kg adult is greater than 7 gm.o Single toxic dose in a child is greater than 150 mg/kg.o Chronic supratherapeutic acetaminophen poisoning is possible as many medications contain

acetaminophen.

Drug Interactions

• Avoid concomitant administration with other acetaminophen-containing medication, such as manyprescription opioids (e.g. Percocet) or OTC cough and cold medications.

Dosage and Administration Adult:

1000 mg PO

Pediatric: 15 mg/kg PO

Protocol

• Pain management

Weight Age Dose

(160 mg/5 mL)

n/a < 6 months BASE CONTACT

5-8kg6 months -12 months

2.5ml (80mg)

9-11kg 1-2 years 4ml (128mg)

12-16kg 2-3 years 5ml (160mg)

17-21kg 4-5 years 7.5ml (240mg)

22-27kg 6-8 years 10ml (320mg)

28-33kg 9-10 years 12.5ml (400mg)

34-43kg 11-12 years 15ml (480mg)

9010 MEDICATIONS

ADENOSINE (ADENOCARD)

Description Adenosine transiently blocks conduction through the AV node thereby terminating reentrant tachycardias involving the AV node. It is the drug of choice for AV nodal reentrant tachycardia (AVNRT, often referred to as “PSVT”). It will not terminate dysrhythmias that do not involve the AV node as a reentrant limb (e.g. atrial fibrillation).

Onset & Duration

• Onset: almost immediate

• Duration: 10 sec

Indications

• Narrow-complex supraventricular tachyarrhythmia after obtaining 12 lead ECG (This may be theonly documented copy of the AVRNT rhythm)

• Pediatric administration requires call in for direct verbal order

Contraindications

• Any irregular tachycardia. Specifically never administer to an irregular wide-complex tachycardia,which may be lethal

• Heart transplant

Adverse Reactions

• Chest pain

• Shortness of breath

• Diaphoresis

• Palpitations

• Lightheadedness

Drug Interactions

• Methylxanthines (e.g. caffeine) antagonize adenosine, a higher dose may be required

• Dipyridamole (persantine) potentiates the effect of adenosine; reduction of adenosine dose may berequired

• Carbamazepine may potentiate the AV-nodal blocking effect of adenosine


12 mg IV bolus, rapidly, followed by a normal saline flush. Additional dose of 12 mg IV bolus, rapidly, followed by a normal saline flush. Contact medical control for further considerations

Pediatric: Children who are stable with AVNRT generally remain so and transport is preferred over intervention.

CONTACT BASE 0.1 mg/kg IV bolus (max 6 mg), rapidly followed by normal saline flush. Additional dose of 0.2 mg/kg (max 12 mg) rapid IV bolus, followed by normal saline flush.


9010 MEDICATIONS

Protocol

• Tachyarrhythmia with Poor Perfusion


• Reliably causes short lived but very unpleasant chest discomfort. Always warn your patient of thisbefore giving medication and explain that it will be a very brief sensation

• May produce bronchospasm in patients with asthma

• Transient asystole and AV blocks are common at the time of cardioversion

• Adenosine is not effective in atrial flutter or fibrillation

• Adenosine is safe in patients with a history of Wolff-Parkinson-White syndrome if the rhythm isregular and QRS complex is narrow

• A 12-lead EKG should be performed and documented, when available

• Adenosine requires continuous EKG monitoring throughout administration


9020 MEDICATIONS

ALBUTEROL SULFATE (PROVENTIL, VENTOLIN)

Description

Albuterol is a selective ß-2 adrenergic receptor agonist. It is a bronchodilator and positivechronotrope.

Because of its ß agonist properties, it causes potassium to move across cell membranes insidecells. This lowers serum potassium concentration and makes albuterol an effective temporizingtreatment for unstable patients with hyperkalemia.

Onset & Duration

Onset: 5-15 minutes after inhalation

Duration: 3-4 hours after inhalation

Indications

• Bronchospasm

• Known or suspected hyperkalemia with ECG changes (i.e.: peaked T waves, QRS widening)

• Crush injuries with peaked T waves, widening QRS or loss of P wave; or hemodynamicallyunstable

Contraindications

Severe tachycardia is a relative contraindication

Adverse Reactions

Tachycardia

Palpitations

Dysrhythmias

Drug Interactions

Sympathomimetics may exacerbate adverse cardiovascular effects.

ß-blockers may antagonize albuterol.

How Supplied MDI: 90 mcg/metered spray (17-g canister with 200 inhalations) Pre-diluted nebulized solution: 2.5 mg in 3 ml NS (0.083%)

Dosage and Administration

Adult: Single Neb dose Albuterol sulfate solution 0.083% (one unit dose bottle of 3.0 ml), by nebulizer, at a flow rate (6-8 lpm) that will deliver the solution over 5 to 15 minutes. May be repeated twice (total of 3 doses). Continuous Neb dose In more severe cases, place 3 premixed containers of albuterol (2.5 mg/3ml) for a total dose of 7.5 mg in 9 ml, into an oxygen-powered nebulizer and run a continuous neb at 6-8 lpm. Crush Injuries doseAdminister 10 mg (in 12 mL) continuous to a max of 20 mg

Pediatric:

Single Neb dose Albuterol sulfate 0.083% (one unit dose bottle of 3.0 ml), by nebulizer, at a flow rate (6-8 lpm) that will deliver the solution over 5-15 minutes. May be repeated twice during transport (total of 3 doses).

Approved by Platteville Gilcrest FPD Medical Director August, 2019.

9020 MEDICATIONS

Protocol

• Adult Wheezing• Pediatric Wheezing

• Allergy and Anaphylaxis

• Crush Injuries


Consider inline nebs for patients requiring endotracheal intubation or CPAP.

May precipitate angina pectoris and dysrhythmias

Should be used with caution in patients with suspected or known coronary disease, diabetesmellitus, hyperthyroidism, prostatic hypertrophy, or seizure disorder

Wheezing associated with anaphylaxis should first be treated with epinephrine IM.


9030 MEDICATIONS

AMIODARONE (CORDARONE)

Description Amiodarone has multiple effects showing Vaughn-Williams Class I, II, III and IV actions with a quick onset. The dominant effect is prolongation of the action potential duration and the refractory period.

Indications

• Pulseless arrest in patients with shock-refractory or recurrent VF/VT

• Wide complex tachycardia not requiring immediate cardioversion due to hemodynamic instability

Precautions

• Wide complex irregular tachycardia

• Sympathomimetic toxidromes, i.e. cocaine or amphetamine overdose

• NOT to be used to treat ventricular escape beats or accelerated idioventricular rhythms

Contraindications

• 2nd or 3rd degree AV block

• Cardiogenic shock

Adverse Reactions

• Hypotension

• Bradycardia


• Pulseless Arrest (Refractory VT/VF):o 300 mg IV bolus.o Administer additional 150 mg IV bolus in 3-5 minutes if shock refractory or recurrent

VF/VT.

• Symptomatic VT and undifferentiated wide complex tachycardia with a pulse:o CONTACT BASE 150 mg in 100 mL NS IV bolus infusion over 10 minutes.

Pediatric:

• Pulseless Arrest (Refractory VT/VF):o 5mg/kg IV bolus.o CONTACT BASE for additional doses.

Protocol

• Universal Pulseless Arrest Algorithm

• Tachycardia with Poor Perfusion


• A 12-lead EKG should be performed and documented, when available.

• Amiodarone is preferred to adenosine for treatment of undifferentiated WCT with a pulse.


9040 MEDICATIONS

ANTIEMETICS: ONDANSETRON (ZOFRAN), PROMETHAZINE (PHENERGAN), METOCLOPRAMIDE (REGLAN)

Description

• Ondansetron is a selective serotonin 5-HT3 receptor antagonist antiemetic. Ondansetron is the preferredantiemetic, if available.

• Promethazine is a non-selective central and peripheral H-1 type histamine antagonist with anticholinergicproperties resulting in antiemetic and sedative effects.

• Metoclopramide is a dopamine antagonist that works by blocking the CNS vomiting chemoreceptor triggerzone (CRT).

Indications

• Nausea and vomiting

Contraindications

• Ondansetron: No absolute contraindication. Should be used with caution in first trimester of pregnancy andshould be reserved for only those patient with severe dehydration and intractable vomiting

• Promethazine: age < 2 years, patients with respiratory or CNS depression or allergy to sulfites.

• Metoclopramide: age < 8 years or suspected bowel obstruction.

Adverse Effects:

• Ondansetron: Very low rate of adverse effects, very well tolerated.

• Promethazine: Hypotension, CNS depression, altered mental status, pain on injection, including tissuenecrosis with extravasation, extrapyramidal symptoms, urinary retention

• Metoclopramide: Restlessness, agitation, extrapyramidal symptoms, sedation. Increased GI motility – do notuse if suspected bowel obstruction.


Ondansetron

Adult: 4 mg IV/IM/PO/ODT. May repeat x 1 dose as needed.

Pediatric ≥ 4 years old:4 mg IV/PO/ODT

Pediatric 6 months to 4 years old: 2 mg IV/PO/ODT

Pediatric < 6 months: BASE CONTACT

Promethazine Adult:

12.5 mg IV/IM. May repeat x 1 dose as needed.

Metoclopramide Adult:

10 mg IV/IM. Pediatric 8-12 years old:

5 mg IV/IM.

Protocol

• Abdominal Pain/Vomiting

• Altitude Illness

Promethazine and Metoclopramide Side effects/Special Notes:

• Drowsiness, dizziness, dry mouth and blurred or double vision are common.

• If hypotension occurs, administer fluid bolus.

• Dystonia and akathisia may occur, and should be treated with diphenhydramine.

• Elderly may become agitated or disoriented. Consider reducing the dose in elderly patients.


9050 MEDICATIONS

ASPIRIN (ASA)

Description Aspirin inhibits platelet aggregation and blood clotting and is indicated for treatment of acute coronary syndrome in which platelet aggregation is a major component of the pathophysiology. It is also an analgesic and antipyretic.

Indications

Suspected acute coronary syndrome

Contraindications

Active gastrointestinal bleeding

Aspirin allergy

How Supplied Chewable tablets 81mg


324mg PO

Protocol

Chest Pain


Patients with suspected acute coronary syndrome taking warfarin (Coumadin), clopidogrel(Plavix) or novel oral anticoagulants may still be given aspirin.


9060 MEDICATIONS

ATROPINE SULFATE

Description Atropine is a naturally occurring antimuscarinic, anticholinergic substance. It is the prototypical anticholinergic medication with the following effects:

Increased heart rate and AV node conduction

Decreased GI motility

Urinary retention

Pupillary dilation (mydriasis)

Decreased sweat, tear and saliva production (dry skin, dry eyes, dry mouth)

Indications

Symptomatic bradycardia

2nd and 3rd degree heart block

Organophosphate poisoning

Precautions

Should not be used without medical control direction for stable bradycardias

Closed angle glaucoma

Adverse Reactions

Anticholinergic toxidrome in overdose, think “blind as a bat, mad as a hatter, dry as a bone, redas a beet”

Dosage and Administration Hemodynamically Unstable Bradycardia

Adult: 0.5 mg IV/IO bolus. Repeat if needed at 3-5 minute intervals to a maximum dose of 3 mg. (Stop at ventricular rate which provides adequate mentation and blood pressure)

Organophosphate: 2 mg initial adult dose and 1 mg if frail/elderly. Base contact for subsequent dosing.(5-10 minutes)

Pediatric: 0.02 mg/kg IV/IO bolus. Minimum dose is 0.1 mg, maximum single dose 0.5 mg

Stable Bradycardia and Poisoning/Overdose

CONTACT BASE

Protocol

Bradycardia with poor perfusion

Poisoning/Overdose


Atropine causes pupil dilation, even in cardiac arrest settings


9070 MEDICATIONS

Approved by Platteville Gilcrest FPD Medical Director June 2020

BENZODIAZEPINES (DIAZEPAM, LORAZEPAM, MIDAZOLAM)

Description Benzodiazepines are sedative-hypnotics that act by increasing GABA activity in the brain. GABAis the major inhibitory neurotransmitter, so increased GABA activity inhibits cellular excitation.Benzodiazepine effects include anticonvulsant, anxiolytic, sedative, amnestic and muscle relaxantproperties. Each individual benzodiazepine has unique pharmacokinetics related to its relativelipid or water solubility.Selection of specific agent as preferred benzodiazepine is at individual agency Medical Directordiscretion.

Onset & Duration Any agent given IV will have the fastest onset of action, typical time of onset 2-3 minutesIntranasal administration has slower onset and is less predictable compared to IV administration,however, it may still be preferred if an IV cannot be safely or rapidly obtained. Intranasal routehas faster onset compared to intramuscular route.

o Diazepam should not be given intranasally as it is not well absorbed.IM administration has the slowest time of onset.

Indications Status epilepticusSedation of the severely agitated/combative patientSedation for cardioversion or transcutaneous pacing (TCP)Adjunctive agent for treatment of severe pain (e.g. back spasms) in adults that is uncontrolled bymaximum opioid dose – WITH CALL IN ONLY

Contraindications HypotensionRespiratory depression

Adverse Reactions Respiratory depression, including apneaHypotensionConsider ½ dosing in the elderly for all benzodiazepines

Dosage and Administration MIDAZOLAM:

Seizure or sedation for cardioversion, transcutaneous pacing or post intubation

Adult: IV/IO route: 2 mg

Dose may be repeated x 1 after 5 minutes if still seizing. Contact Base for more than 2 doses 0.05 mg/kg for sedation post intubation. (Contact medical control for further direction if

initial dose does not work)

IN/IM route (intranasal preferred): 5 mg

Sedation post intubation when patient is visibly biting at the tube or waking up post ROSC

Dose may be repeated x 1 after 5 minutes if still seizing. Contact Base for more than2 doses

•

9070 MEDICATIONS


Pediatric: IV/IO route 0.1 mg/kg

Maximum single dose is 2 mg IV. Dose may be repeated x 1 after 5 minutes if stillseizing. Contact Base for more than 2 doses.

IN/IM route (intranasal preferred): 0.2 mg/kg. Maximum single dose is 5 mg IN or IM. Dose may be repeated x 1 after 5 minutes ifstill seizing. Contact Base for more than 2 doses.

Sedation of severely agitated or combative patient

Adult: IV route: 2 mg IN/IM route: 5 mg

Dose may be repeated x 1 after 5 minutes. Contact base for more than 2 doses,unless Excited Delirium Syndrome present, in which case up to a total of 3 dosesmay be given as standing order in order to rapidly sedate patient.

Pediatric: CONTACT BASE before any consideration of sedation of severelyagitated/combative child

DIAZEPAM:

Seizure or sedation for cardioversion or transcutaneous pacing:



Pediatric: IV/IO route 0.3 mg/kg

Maximum single dose is 5 mg IV. Dose may be repeated x 1 after 5 minutes if stillseizing. Contact Base for more than 2 doses.


Adult: IV route: 5 mg

Dose may be repeated x 1 after 5 minutes. Contact base for more than 2 doses,unless Excited Delirium Syndrome present, in which case up to a total of 3 dosesmay be given as standing order in order to rapidly sedate patient


LORAZEPAM: Seizure or sedation for cardioversion or transcutaneous pacing:



IN/IM route (intranasal preferred): 2 mg Dose may be repeated x 1 after 5 minutes if still seizing. Contact Base for more than2 doses

9070 MEDICATIONS


Pediatric: IV route: 0.05 mg/kg


IN/IM route (intranasal preferred): 0.1 mg/kg Dose may be repeated x 1 after 5 minutes if still seizing. Contact Base for more than2 doses


Adult: IV route: 2 mg IN/IM route: 2 mg

Dose may be repeated x 1 after 5 minutes. Contact base for more than 2 doses,unless Excited Delirium Syndrome present, in which case up to a total of 3 dosesmay be given as standing order in order to rapidly sedate patient


Protocol Synchronized CardioversionTranscutaneous PacingSeizurePoisoning/OverdoseAgitated/Combative Patient

Special Considerations All patients receiving benzodiazepines must have cardiac, pulse oximetry monitoring duringtransport. Continuous waveform capnography recommended.Sedative effects of benzodiazepines are increased in combination with opioids, alcohol, or otherCNS depressants.Coadministration of opioids and benzodiazepines is discouraged and may only be done withdirect physician verbal order.In elderly patients > 65 years old or small adults < 50kg, lower doses may be sufficient andeffective. Consider ½ dosing in these patients.

9075 MEDICATIONS

BENZODIAZEPINES (DIAZEPAM, LORAZEPAM)- ORAL Description

● Benzodiazepines are sedative-hypnotics that act by increasing GABA activity in the brain. GABA is the major inhibitory neurotransmitter, so increased GABA activity inhibits cellular excitation. Benzodiazepine effects include anticonvulsant, anxiolytic, sedative, amnestic and muscle relaxant properties. Each individual benzodiazepine has unique pharmacokinetics related to its relative lipid or water solubility.

● Selection of specific agent as preferred benzodiazepine is at individual agency Medical Director discretion.

Onset & Duration

● Any agent given IV will have the fastest onset of action, typical time of onset 2-3 minutes ● Intranasal administration has slower onset and is less predictable compared to IV

administration, however, it may still be preferred if an IV cannot be safely or rapidly obtained. Intranasal route has faster onset compared to intramuscular route.

● Diazepam should not be given intranasally as it is not well absorbed. ● IM administration has the slowest time of onset. ● A single dose of oral diazepam will be one of the most rapidly absorbed

benzodiazepines which along with a quick onset will have a short duration of action despite the long half-life of the drug.

Indications

● Severe Anxiety ● Sedation for Cardioversion or TCP

Contraindications

● Respiratory Depression ● Hypotension

Adverse Reactions

● Respiratory Depression including Apnea ● Hypotension

Dosage and Administration DIAZEPAM

● 2 mg Oral LORAZEPAM

● 0.5 mg Oral Special Considerations

● All patients receiving benzodiazepines must have cardiac, pulse oximetry monitoring during transport. Continuous waveform capnography recommended.

● Sedative effects of benzodiazepines are increased in combination with opioids, alcohol, or other CNS depressants.

● Coadministration of opioids and benzodiazepines is discouraged and may only be done with direct physician verbal order.

● In elderly patients > 65 years old or small adults < 50kg, lower doses may be sufficient and effective. Consider 1⁄2 dosing in these patients.


9080 MEDICATIONS

CALCIUM

Description • Cardioprotective agent in hyperkalemia.

• Calcium chloride contains 3 times the amount of elemental calcium contained in the same volume ofcalcium gluconate. Therefore, 1 g (10 mL) vial of calcium chloride 10% solution contain 273 mg ofelemental calcium, whereas 1 g (10 mL) of 10% calcium gluconate contains 90 mg of elementalcalcium. For this reason, larger doses of calcium gluconate are required.

• Doses below refer to dose of calcium solution, not elemental calcium.

Indications • Adult pulseless arrest associated with any of the following clinical conditions:

o Known hyperkalemiao Renal failure with or without hemodialysis historyo Calcium channel blocker overdose

• Not indicated for routine treatment of pulseless arrest

• Calcium channel blocker overdose with hypotension and bradycardia

• Crush injuries with peaked T waves, widening QRS or loss of P wave; or hemodynamically unstable

Contraindications

• Known hypercalcemia

• Suspected digoxin toxicity (i.e. digoxin overdose)

Side Effects/Notes

• Extravasation of calcium chloride solution may cause tissue necrosis.

• Because of the risk of medication error, if calcium chloride is stocked, consider limiting to 1 amp permedication kit to avoid accidental overdose. Calcium gluconate solution will require 3 amp supply forequivalent dose.

• Must give in separate line from IV sodium bicarb to prevent precipitation/formation of calciumcarbonate.

• In setting of digoxin toxicity, may worsen cardiovascular function.


Calcium Gluconate 10% Solution

Adult:

• Pulseless arrest assumed due to hyperkalemia:o 3 g (30 mL) slow IV/IO push

• Calcium channel blocker overdose with hypotension and bradycardia:o Contact Base for order. 3 g (30 mL) slow IV/IO push. Dose may be repeated every 10

minutes for total of 3 doses• Crush injuries:

o 1 g (10 mL) slow IV/IO push (over 2-3 minutes)o Contact Base for repeat dose if no EKG change after 5 minutes

Pediatric:

• Calcium channel blocker overdose with hypotension for age and bradycardia:o Contact Base for order. 60 mg/kg (0.6 mL/kg), not to exceed 3 g slow IV/IO push not to

exceed 2 mL/minute, may repeat every 10 minutes for total of 3 doses

Calcium Chloride 10% Solution

Adult:

• Pulseless arrest assumed due to hyperkalemia:o 1 g (10 mL) slow IV/IO push

• Calcium channel blocker overdose with hypotension and bradycardia:o Contact Base for order. 1 g (10 mL) slow IV/IO push. Dose may be repeated every 10

minutes for total of 3 doses• Crush injuries:

o 1 g (10 mL) slow IV/IO push (over 2-3 minutes)o Contact Base for repeat dose if no EKG change after 5 minutes

• Universal Pulseless Arrest

• Poisoning/Overdose

• Crush Injuries

Protocol


• Calcium channel blocker overdose with hypotension for age and bradycardia:o Contact Base for order. 20 mg/kg (0.2 mL/kg), not to exceed 1 g slow IV/IO push not to

exceed 1 mL/min, may repeat every 10 minutes for total of 3 doses.

Pediatric:

9090 MEDICATIONS

DEXTROSE

Description Glucose is the body's basic fuel and is required for cellular metabolism. A sudden drop in blood sugar level will result in disturbances of normal metabolism, manifested clinically as a decrease in mental status, sweating and tachycardia. Further decreases in blood sugar may result in coma, seizures, and cardiac arrhythmias. Serum glucose is regulated by insulin, which stimulates storage of excess glucose from the blood stream, and glucagon, which mobilizes stored glucose into the blood stream.

Indications

• Hypoglycemia

• The unconscious or altered mental status patient with an unknown etiology.

Precautions

• None


25 gm (250 mL of a 10% solution) IV/IO infusion Alternative: 25 gm (50 mL of a 50% solution) IV/IO bolus

Pediatric: <50 kg administer 5 mL/kg of 10% solution (maximum of 250 mL)

Protocol

• Hypoglycemia

• Universal Altered Mental Status

• Seizures


• Psych/Behavioral


• The risk to the patient with ongoing hypoglycemia is enormous. With profound hypoglycemia andno IV access consider IO insertion.

• Draw blood sample before administration, if possible.

• Use glucometer before administration, if possible.

• Extravasation may cause tissue necrosis; use a large vein and aspirate occasionally to ensureroute patency.

• Dextrose can be irritable to the vein and the vein should be flushed after administration.


9100 MEDICATIONS

DIPHENHYDRAMINE (BENADRYL)

Description Antihistamine for treating histamine-mediated symptoms of allergic reaction. Also anticholinergic and antiparkinsonian effects used for treating dystonic reactions caused by antipsychotic and antiemetic medications (e.g.: haloperidol, droperidol, reglan, compazine, etc).

Indications

• Allergic reaction

• Dystonic medication reactions or akathisia (agitation or restlessness)

Precautions

• Asthma or COPD, thickens bronchial secretions

• Narrow-angle glaucoma

Side effects

• Drowsiness

• Dilated pupils

• Dry mouth and throat

• Flushing

Drug Interactions

• CNS depressants and alcohol may have additive effects.

• MAO inhibitors may prolong and intensify anticholinergic effects of antihistamines.

Dosage and Administration Adults: 50 mg IV/IO/IM Pediatrics: 1 mg/kg slow IV/IO/IM (not to exceed 50 mg)

Protocol

• Allergy/Anaphylaxis


9115 MEDICATIONS

DuoDote™ (NERVE AGENT ANTIDOTE KIT)

Description

Nerve agents can enter the body by inhalation, ingestion, and through skin. These agents are absorbed rapidly and can produce injury or death within minutes. The DuoDote™ Nerve Agent Antidote kit consists of one auto-injector for self and/or buddy administration. One Injector contains 2.1mg atropine and 600mg pralidoxime chloride (2-PAM)

Indications

• Suspected nerve agent exposure accompanied with signs and symptoms of nerve agent poisoning

Injection sites

• Outer thigh- mid-lateral thigh (preferred site)

• Buttocks- upper lateral quadrant of buttock (gluteal) in thin individuals

Instructions

• Place the auto-injector in the dominate hand. Firmly grasp the center of the auto injector withthe green tip (needle end) pointing down.

• With the other hand, pull off the gray safety release. The DuoDote™ auto-injector is now ready

to be administered.


9115 MEDICATIONS

• The injection site is the mid-outer thigh. The DuoDote™ auto-injector can inject through clothing.

However, make sure pockets at the injection site are empty.

• Swing and firmly push the green tip at a 90-degree angle against the mid-outer thigh. Continue

to firmly push until you feel the auto injector trigger.

• No more than three (3) sets of antidotes should be administered.


• Presence of tachycardia is not a reliable indicator of effective treatment due to potential nicotiniceffects of nerve agent exposure. The end-point of treatment is clear dry lung sounds.

• Attempt to decontaminate skin and clothing between injections.

Protocol:

• Overdose and Acute Poisoning


9120 MEDICATIONS


EPINEPHRINE (ADRENALIN)

Description Endogenous catecholamine alpha, beta-1, and beta-2 adrenergic receptor agonist. Causes dose-related increase in heart rate, myocardial contractility and oxygen demand, peripheral vasoconstriction and bronchodilation.

Indications • Pulseless Arrest• Anaphylaxis• Asthma• Bradycardia with poor perfusion

Adverse Reactions • Tachycardia and tachydysrhythmia• Hypertension• Anxiety• May precipitate angina pectoris

Drug Interactions • Should not be added to sodium bicarbonate or other alkaloids as epinephrine will be inactivated

at higher pH.


Pulseless Arrest 1 mg (10 ml of a 1:10,000 solution), IV/IO bolus. Repeat every 3-5 minutes up to maximum of 3 doses. Additional dose may be considered for recurrent arrest after ROSC or narrow complex PEA. Bradycardia with hypotension and poor perfusion refractory to other interventions Continuous infusion titrated to effect: see Vasopressor infusion Asthma: 0.3 mg (0.3 ml of a 1:1,000 solution) IM. May repeat dose x 1. Systemic allergic reaction: 0.3 mg (0.3 ml of a 1:1,000 solution) IM. May repeat dose x 1. Severe systemic allergic reaction (Anaphylaxis) refractory to IM epinephrine: Continuous infusion titrated to effect: see Vasopressor infusion ALTERNATIVE to racemic epinephrine: (for stridor at rest) 5 mL of 1:1,000 epinephrine via nebulizer x 1

Epinephrine Auto-Injector: Systemic allergic reaction: Adult: 0.3 mg IM with autoinjector (adult EpiPen, Auvi-Q) Pediatric: 0.15 mg IM with autoinjector (EpiPen Jr., Auvi-Q)

Pediatric: Pulseless arrest: 0.01 mg/kg IV/IO (0.1 ml/kg of 1:10,000 solution). Subsequent doses repeated every 3-5min: 0.01 mg/kg IV/IO (0.1 ml/kg of 1:10,000 solution) Bradycardia (CONTACT BASE) 0.01 mg/kg (0.1 ml/kg of 1:10,000 solution) IV/IO Asthma 0.01 mg/kg (0.01 ml/kg of 1:1,000 solution) IM Alternative: 0.15 mg (0.15 mL of 1:1,000) for <25 kg and 0.3 mg (0.3 mL of 1:1,000) for >25 kg

9120 MEDICATIONS

Moderate to Severe Allergic Reactions 0.01 mg/kg (0.01 ml/kg of 1:1,000 solution) IM Alternative: 0.15 mg (0.15 mL of 1:1,000) for <25 kg and 0.3 mg (0.3 mL of 1:1,000) for >25 kg Severe systemic allergic reaction (Anaphylaxis) refractory to IM epi (Contact Base): 0.01 mg/kg (0.1 ml/kg of 1:10,000 solution) IV/IO ALTERNATIVE to racemic epinephrine: (for stridor at rest) 5 mL of 1:1,000 epinephrine via nebulizer x 1

Protocol • Universal Pulseless Arrest Algorithm• Bradyarrhythmia with poor perfusion• Neonatal Resuscitation• Allergy and Anaphylaxis Protocol• Adult Wheezing• Pediatric Wheezing• Vasopressor Infusion

Special Considerations • May increase myocardial oxygen demand and angina pectoris. Use with caution in patients with

known or suspected CAD• Intramuscular injection into the thigh is preferred route and site of administration. Intramuscular

injection of epinephrine in the thigh results in higher concentrations of medication versusintramuscular or subcutaneous injection in the upper arm.


9130 MEDICATIONS

GLUCAGON

Description Increases blood sugar concentration by converting liver glycogen to glucose. Glucagon also causes relaxation of smooth muscle of the stomach, duodenum, small bowel, and colon.

Onset & Duration

• Onset: variable

Indications

• Altered level of consciousness where hypoglycemia is suspected and IV access is unavailable.

• Hypotension, bradycardia from beta-blocker or calcium channel overdose.

Side Effects

• Tachycardia

• Headache



Hypoglycemia:

• 1 mg IMBeta Blocker/Calcium Channel overdose with hypotension and bradycardia:

• 2 mg IV bolus

Pediatric: Hypoglycemia:

• < 25 kg: 0.5 mg IM.

• > 25 kg: 1 mg IMBeta Blocker/Calcium Channel overdose with hypotension for age, signs of poor perfusion and bradycardia:

• 0.1 mg/kg IV Bolus, max initial dose 2 mg IV

Protocol

• Hypoglycemia



9140 MEDICATIONS

HALOPERIDOL (HALDOL)

Description Haloperidol is a butyrophenone antipsychotic medication. Haloperidol produces a dopaminergic blockade, a mild alpha-adrenergic blockade, and causes peripheral vasodilation. Its major actions are sedation and tranquilization.

Onset & Duration

• Onset: Within 10 minutes after IM administration. Peak effect within 30 minutes

• Duration: 2-4 hours (may be longer in some individuals)

Indications

• Sedation of a severely agitated and/or combative patient

Contraindications

• Suspected myocardial infarction

• Hypotension

• Respiratory or CNS depression

• Pregnancy

Precautions

• Haldol may cause hypotension, tachycardia, and prolongation of the QT interval. Use withcaution in severe cardiovascular disease.

• Cardiac monitor and establish an IV as soon as possible with all administrations.

• Some patients may experience unpleasant sensations manifested as restlessness, hyperactivity,or anxiety following haloperidol administration.

• Rare instances of neuroleptic malignant syndrome (very high fever, muscular rigidity) have beenknown to occur after the use of haloperidol.

Dosage and Administration Adults: 5-10 mg IM

Pediatrics (not for use in children <6 years): BASE CONTACT Ages 6-12: 2 mg IM

BASE CONTACT must be made for additional doses (consider if no effects within 10 minutes)


• Extra-pyramidal reactions have been noted hours to days after treatment, usually presenting asspasm of the muscles of the tongue, face, neck, and back. This may be treated withdiphenhydramine.

• Hypotension and tachycardia secondary to haloperidol are usually self-limiting and should betreated with IV fluid bolus.

• Use one half dose in patients age ≥ 65 who are at increased risk of complications.

Protocol

• Agitated/Combative Patient Protocol


9150 MEDICATIONS

HEMOSTATIC AGENT (QuickClot, Celox, Bloodstop, Actcel, HemCon, ChitoGauze)

Description

QuickClot Combat Gauze is a standard roller or Z-fold gauze impregnated with a clotting agent such as kaolin (a clay containing the active ingredient aluminum silicate) which works on contact with blood to initiate the clotting process (intrinsic pathway) by activating factor XII. This reaction leads to the transformation of factor XII to its’ activated form XIIa, which triggers the clotting cascade.

Mucoadhesive agents such as HemCon, ChitoGauze and Celox utilize a granular chitosan salt derived from the shells of marine arthropods (which are positively charged) to react with and bind to negatively charged red blood cells rapidly forming a cross-linked barrier clot to seal the injured vessels.

Used in conjunction with direct pressure and wound packing these products lead to hemostasis.

Onset and Duration

• Onset of action is 3-5 minutes after wound exposure and clotting action remains unlessthe dressing and/or the clot is disturbed.

Indications

• Active bleeding from open wounds with that cannot be controlled with direct pressure.Most often involving wounds to the scalp, face, neck, axilla, groin or buttocks.

Contraindications • Not to be used to treat internal bleeding such as intra-abdominal, intra-thoracic or

vaginal bleeding.

• Not to be used for minor bleeding that can be controlled by direct pressure.

Precautions

• Bleeding control is achieved via combination of direct pressure and hemostatic gauzepacking for a minimum of 3-5 minutes.

• Stabilize patient per General Trauma Care Protocol.

• If a tourniquet is indicated (refer to Tourniquet Protocol), it should be applied first, beforeapplication of hemostatic agent.

• DO NOT USE LOOSE GRANULAR OR POWDERED HEMOSTATIC AGENTS. Theseare out date and will produce exothermic reactions that may cause burns and additionaltissue damage.

Procedure 1. Manufacturers may have different recommendations on application of their products.

Follow specific manufacturer guidelines for the particular product carried.


9160 MEDICATIONS

HYDROXOCOBALAMIN (CYANOKIT)

Description

• Cyanide inhibits cytochrome oxidase, thereby arresting cellular respiration and forcing anaerobicmetabolism, which leads to lactate production and acidosis and ultimately death. Hydroxocobalaminbinds cyanide ions to form cyanocobalamin which is excreted in urine.

Indications

• Adult or pediatric patient with suspected cyanide poisoning from any route, including smoke inhalation inan enclosed space, with any of the following clinical signs:

o Pulseless arresto Coma/unresponsivenesso Signs of shock

Precautions

• Administer only after basic life support measures have been initiated and always in conjunction withother supportive treatment modalities.

Adverse Reactions

• Hypertension

• Allergic reaction/anaphylaxis


• Dosingo Adult dose is 5 gm IVo Pediatric dose is 70 mg/kg up to 5 gm IV

• 5 gm vial instructions:1. The Cyanokit consists of a 5 gm vial of hydroxocobalamin2. Reconstitute: Place the vial in an upright position. Add 200 mL

of 0.9% Sodium Chloride Injection* to the vial using the transferspike. Fill to the line. *0.9% Sodium Chloride Injection is therecommended diluent (diluent not included in the kit). LactatedRinger’s Solution and 5% Dextrose Injection have also beenfound to be compatible with hydroxocobalamin.

3. Mix: The vial should be repeatedly inverted or rocked, notshaken, for at least 60 seconds prior to infusion.

4. Infuse Vial: Use vented intravenous tubing, hang and infusedesired dose over 15 minutes.


• It is understood that Cyanokit may not be available to all agencies at all times and therefore is notconsidered standard of care. Notify receiving facility if Cyanokit used.

Protocols

• Carbon Monoxide Exposure

• Burns

Average Weight

by Group

Grey 4 kg

Pink 6.5 kg

Red 8.5 kg

Purple 10.5 kg

Yellow 13 kg

White 16.5 kg

Blue 21 kg

Orange 26.5 kg

Green 33 kg Adult

Dose 275mg (11mL)

450mg (18mL)

600mg (24mL)

725mg (29mL)

900mg (36mL)

1150mg (46mL)

1475mg (59mL)

1850mg (74mL)

2300mg (92mL)

5000mg (200mL)


9165 MEDICATIONS


IBUPROFEN (ADVIL,MOTRIN)

Description Ibuprofen is a non-steroidal anti-inflammatory drug (NSAID) that inhibits synthesis of prostaglandins in body tissues by inhibiting at least 2 cyclo-oxygenase (COX) isoenzymes, COX-1 and COX-2. May inhibit chemotaxis, alter lymphocyte activity, decrease proinflammatory cytokine activity, and inhibit neutrophil aggregation; these effects may contribute to anti-inflammatory activity

Onset & Duration

• Onset: 30-60 minutes

• Duration: 6-8 hours

Indications

• Mild pain

Contraindications

• Aspirin or NSAID allergy

• Peptic ulcer disease

• Chronic kidney disease

• Anticoagulated patient

Adverse Reactions

• Allergy/anaphylaxis

• Hives, angioedema, bronchospasm, rash, hypotension, etc.

Drug Interactions

• Avoid concomitant administration with other NSAID within past 6 hours.


600 mg PO

Pediatric: 10 mg/kg PO

Protocol

• Pain management

Weight Age Dose

(100 mg/5 mL)

n/a < 6 months DO NOT GIVE

5-8kg6 months- 12 months

3 mL (60 mg)

9-11kg 1-2 years 4 mL (80 mg)

12-16kg 2-3 years 5 mL (100 mg)

17-21kg 4-5 years 7.5 mL (150 mg)

22-27kg 6-8 years 10 mL (200 mg)

28-33kg 9-10 years 15 mL (300 mg)

34-43kg 11-12 years 20 mL (400mg)

9170 MEDICATIONS

IPRATROPIUM BROMIDE (ATROVENT)

Description Ipratropium is an anticholinergic bronchodilator chemically related to atropine.

Onset & Duration

Onset: 5-15 minutes.

Duration: 6-8 hours.

Indications

Bronchospasm

Contraindications

Do not administer to children < 2 years

Soy or peanut allergy is a contraindication to the use of Atrovent metered dose inhaler, not thenebulized solution, which does not have the allergen contained in propellant.

Adverse Reactions

Palpitations

Tremors

Dry mouth

How Supplied Premixed Container: 0.5 mg in 2.5ml NS


Adult Bronchospasm:

Ipratropium (0.5 mg/2.5 ml) along with albuterol in a nebulizer. May repeat 1 time.

Child (2 yrs – 12 yrs) Mod and Severe Bronchospasm

Ipratropium (0.5 mg/2.5 ml) along with albuterol in a nebulizer Not indicated for repetitive dose or continuous neb use

Protocol

Adult Wheezing

Pediatric Wheezing


9175 Medications

KETAMINE Description

Ketamine is a non-competitive NMDA receptor antagonist which produces complex neuroinhibition resulting in dissociative amnestic and analgesic effects.

Onset & Duration

● Onset: IV – Immediate, 1-5 minutes after IM administration. ● Duration: 10-15 minutes

Indications

● Analgesia adjunct and alternative to opioid administration, intended to be first line therapy or second line therapy in situations where extreme pain has been unrelieved with appropriate opioid treatment.

Contraindications

● Relatively contraindicated in penetrating eye trauma

Side Effects

● Laryngospasm: this very rare adverse reaction presents with stridor and respiratory distress. After every administration of ketamine:

a. Prepare to provide respiratory support including bag-valve-mask ventilation and suction which are generally sufficient in rare cases of laryngospasm.

b. Institute cardiac monitoring, pulse oximetry and continuous waveform capnography

c. Establish IV or IO access, check blood glucose d. Establish and maintain physical restraint.

● Emergence reaction: presents as anxiety, agitation, dysphoria, apparent hallucinations or nightmares as ketamine is wearing off. For severe reactions, consider benzodiazepine.

● Nausea and Vomiting: always have suction available after ketamine administration. Administer antiemetic as needed.

● Hypersalivation: Suction usually sufficient.

9175 Medications


Analgesia Adults:

● Slow bolus/infusion of 0.25 mg/kg IV ● 0.5 mg/kg IN/IM

● Contact base for additional doses

Pediatric 13 years and older:

● Slow bolus/infusion of 0.25 mg/kg IV

● 0.5 mg/kg IN/IM

● Contact base for additional doses


● Ketamine is provided for administration in vials of 200 mg/20 mL concentration (10 mg / 1 mL).

● Slow IV push should be done over a 2-3 minute timeframe. ● For infusion mix in 100mL NS bag with a macro drip set. Set drip rate to a

moderate TKO rate to infuse over a 2-3 minute time period. (18g IV with a WO drip set will deliver fluid in approximately 1 minute)

● All cases of ketamine use will be reviewed by the Medical Director.

Protocol

Analgesia

● Extremity Injuries

● Abdominal Pain

● Amputations

● Burns

● Bites/Stings/Snake Bites

● Face and Neck Trauma

● Chest Trauma

● Abdominal Trauma

● Spinal Trauma

9180 MEDICATIONS

LIDOCAINE 2% SOLUTION

Description Local anesthetic for relief of pain during intraosseous fluid administration.

Indications

• Analgesic for intraosseous infusion

Side Effects

• Seizures

• Drowsiness

• Tachycardia

• Bradycardia

• Confusion

• Hypotension

Precautions

• Lidocaine is metabolized in the liver. Elderly patients and those with liver disease or poor liverperfusion secondary to shock or congestive heart failure are more likely to experience side effects

Dosage and Administration Adult and Pediatric:

• 0.5 mg/kg IO bolus, slowly, maximum dose is 50 mg

Protocol Intraosseous Procedure

Special Notes

• Seizure from lidocaine toxicity likely to be brief and self-limited. If prolonged, or status epilepticus,treat per seizure protocol

• Treat dysrhythmias according to specific protocol

Lidocaine Jelly 2%:

• Indication – Anesthetic lubricant for nasotracheal intubation• Contraindication – Known history of hypersensitivity to local

anesthetics• Dosage and Administration

o Apply a moderate amount of jelly to the endotracheal tubeshortly before use.

o Avoid introducing the jelly into the lumen of the tubeo If jelly has dried before insertion, reapply


9190 MEDICATIONS

MAGNESIUM SULFATE

Description Magnesium sulfate reduces striated muscle contractions and blocks peripheral neuromuscular transmission by reducing acetylcholine release at the myoneural junction. In cardiac patients, it stabilizes the potassium pump, correcting repolarization. It also shortens the Q-T interval in the presence of ventricular arrhythmias due to drug toxicity or electrolyte imbalance. In respiratory patients, it may act as a bronchodilator in acute bronchospasm due to asthma or other bronchospastic diseases. In patients suffering from eclampsia, it controls seizures by blocking neuromuscular transmission and lowers blood pressure as well as decreases cerebral vasospasm.

Indications Antiarrhythmic

Torsade de pointes associated with prolonged QT intervalRespiratory

Severe bronchospasm unresponsive to continuous albuterol, ipratropium, and IM epinephrine.Obstetrics

Eclampsia: Pregnancy > 20 weeks gestational age or post partum with seizures

Precautions

Bradycardia

Hypotension

Respiratory depression

Adverse Reactions

Bradycardia

Hypotension

Respiratory depression


Torsades de Pointes suspected caused by prolonged QT interval:o 2 gm, IV bolus.

Refractory Severe Bronchospasm:o 2 gm, IV bolus, over 2 minutes.

Eclampsia:o 2 gm, IV bolus slowlyo Mix 4 gm, diluted in 50 ml of Normal Saline (0.9 NS), IV drip over 15-30 minutes.

Protocol

Universal Pulseless Arrest Algorithm

Adult wheezing

Obstetric Complications


9200 MEDICATIONS

METHYLPREDNISOLONE (SOLU-MEDROL)

Description Methylprednisolone is a synthetic steroid that suppresses acute and chronic inflammation and may alter the immune response. In addition, it potentiates vascular smooth muscle relaxation by beta-adrenergic agonists and may alter airway hyperactivity.

Indications

Anaphylaxis

Severe asthma

COPD

Suspected Addisonian crisis (cardiovascular collapse in patient at risk for adrenal insufficiency)

Contraindications

Evidence of active GI bleed

Adverse Reactions Most adverse reactions are a result of long-term therapy and include:

Gastrointestinal bleeding

Hypertension

Hyperglycemia


125 mg, IV/IO bolus, slowly, over 2 minutes Pediatric:

2 mg/kg, IV/IO bolus, slowly, over 2 minutes to max dose of 125 mg

Protocol

Adult Wheezing

Pediatric Wheezing

Allergy and Anaphylaxis

Medical Hypotension/shock

Adrenal Insufficiency


Must be reconstituted and used immediately

The effect of methylprednisolone is generally delayed for several hours.

Methylprednisolone is not considered a first line drug. Be sure to attend to the patient’s primarytreatment priorities (i.e. airway, ventilation, beta-agonist nebulization) first. If primary treatmentpriorities have been completed and there is time while in route to the hospital, thenmethylprednisolone can be administered. Do not delay transport to administer this drug


9210 MEDICATIONS

NALOXONE (NARCAN)

Description Naloxone is a competitive opioid receptor antagonist

Onset & Duration Onset: Within 5 minutes Duration: 1-4 hours

Indications

• For reversal of suspected opioid-inducted CNS and respiratory depression

• Coma of unknown origin with impaired airway reflexes or respiratory depression

Adverse Reactions

• Tachycardia


• Pulmonary Edema


0.5 mg IV/IO/IM/IN and titrate to desired effect, up to 2 mg total In cases of severe respiratory compromise or arrest, 2 mg bolus IV/IO/IM is appropriate, otherwise drug should be titrated

With some newer synthetic opioid formulations, higher doses of naloxone may be required. In rare cases of confirmed or strongly suspected opioid overdose with insufficient response to 2mg, higher doses may be used, titrate to effect. Routine use of high dose naloxone should be avoided.

Pediatrics: 0.5 mg IV/IO/IM/IN and titrate to desired effect, up to 2 mg total

Protocol

• Universal Altered Mental Status

• Drug/Alcohol Intoxication



• Not intended for use unless respiratory depression or impaired airway reflexes are present.Reversal of suspected mild-moderate opioid toxicity is not indicated in the field as it may greatlycomplicate treatment and transport as narcotic-dependent patients may experience violentwithdrawal symptoms

• Patients receiving EMS administered naloxone should be transported to a hospital.

• In the State of Colorado, bystanders, law enforcement, and other first responders can administernaloxone if they feel a person is experiencing an opiate-related drug overdose event (ColoradoRevised Statutes §12-36-117.7).

(continued next page)


https://advance.lexis.com/api/document/collection/statutes-legislation/id/5PC1-82W0-004D-14CT-00008-00?cite=C.R.S.%2012-36-117.7&context=1000516

9210 MEDICATIONS

• There are significant concomitant inherent risks in patients who have received naloxone,including:

o Recurrent respiratory/CNS depression given short half-life of naloxoneo Co-existing intoxication from alcohol or other recreational or prescription drugso Acetaminophen toxicity from combination opioid/acetaminophen prescriptionso Non-cardiogenic pulmonary edema associated with naloxone useo Acute psychiatric decompensation, overdose, SI/HI or psychosis requiring ED evaluationo Sudden abrupt violent withdrawal symptoms which may limit decision making capacity

• Given the above risks, it is strongly preferred that patients who have received naloxone betransported and evaluated by a physician. However, if the patient clearly has decision-makingcapacity he/she does have the right to refuse transport. If adamantly refusing, patients must bewarned of the multiple risks of refusing transport.

• If the patient is refusing transport contact base. If any concerns or doubts about decision-makingcapacity exist, err on the side of transport.


9220 MEDICATIONS

NITROGLYCERIN (NITROSTAT, NITROQUICK, etc)

Description Short-acting peripheral venodilator decreasing cardiac preload and afterload

Onset & Duration Onset: 1-3 min. Duration: 20-30 min.

Indications

• Pain or discomfort due to suspected Acute Coronary Syndrome

• Pulmonary edema due to congestive heart failure

Contraindications

• Suspected right ventricular ST-segment elevation MI (Inferior STEMI pattern plus ST elevation inright sided-precordial leads)

• Hypotension SBP < 100

• Recent use of erectile dysfunction (ED) medication (e.g. Viagra, Cialis)

Adverse Reactions

• Hypotension

• Headache

• Syncope


• Chest Pain: 0.4 mg (1/150 gr) sublingually, every 5 minutesPRN up to a total of 3 doses for persistent CP

• Pulmonary Edema: 0.4 mg (1/150 gr) sublingually, every 5 minutes PRN titrated to symptomsand blood pressure

• Nitropaste: system specific protocol

Protocol

• Chest Pain

• CHF/Pulmonary Edema


9230 MEDICATIONS


OPIOIDS (FENTANYL, MORPHINE, HYDROMORPHONE)

Description Opioid analgesics with desired effects of analgesia, euphoria and sedation as well as undesired effects of respiratory depression and hypotension. A synthetic opioid, fentanyl is 100 times more potent than morphine, and is less likely to cause histamine release.

Indications Treatment of hemodynamically stable patients with moderate to severe pain due to traumatic ormedical conditions.

Contraindications Fentanyl - Hemodynamic instability or shockMorphine and hydromorphone – Hypotension, hemodynamic instability, or shockRespiratory depression

Caution/Comments: Opioids should only be given to hemodynamically stable patients and titrated slowly to effect.The objective of pain management is not the removal of all pain, but rather, to make the patient’spain tolerable enough to allow for adequate assessment, treatment and transportRespiratory depression, including apnea, may occur suddenly and without warning, and is morecommon in children and the elderly. Start with ½ traditional dose in the elderly.Coadministration of opioids and benzodiazepines is discouraged and may only be done withdirect physician verbal order.Chest wall rigidity has been reported with rapid administration of fentanyl


FENTANYL: Adult doses may be rounded to nearest 25 mcg incrementInitial dose in adults typically 100 mcgStrongly consider ½ typical dosing in elderly or frail patient

Adult:IV/IO route: 1-2 mcg/kg.

Dose may be repeated after 5 minutes and titrated to clinical effect to a maximumcumulative dose of 3 mcg/kgAdditional dosing requires BASE CONTACT

IN route: 1-2 mcg/kg. Dose may be repeated after 10 minutes after initial IN dose to a maximum cumulativedose of 3 mcg/kg. IV route is preferred for repeat dosing.Additional dosing requires BASE CONTACT

Pediatric (1-12 years): IV/IO route: 1-2 mcg/kg.

Dose may be repeated after 5 minutes and titrated to clinical effect to a maximumcumulative dose of 3 mcg/kg.Additional dosing requires BASE CONTACT

9230 MEDICATIONS


IN route: 2 mcg/kg. Administer a maximum of 1 ml of fluid per nostrilDose may be repeated after 10 minutes after initial IN dose to a maximum cumulativedose of 4 mcg/kg. IV route is preferred for repeat dosing.

Pediatric < 1 year: BASE CONTACT

MORPHINE: Adult:

IV/IO/IM routes: 5-10 mg. Dose may be repeated after 10 minutes and titrated to clinical effect to a maximumcumulative dose of 10 mg.Additional cumulative dosing > 10 mg requires BASE CONTACT.Morphine may not be given IN as it is poorly absorbed

Pediatric (1-12 years): IV/IO/IM routes: 0.1 mg/kg. Maximum single dose is 6 mg

Dose may be repeated after 10 minutes and titrated to clinical effect up to maximumcumulative dose of 0.2 mg/kg or 10 mg.Additional cumulative dosing requires BASE CONTACT.Morphine may not be given IN as it is poorly absorbed

Pediatric < 1 year: BASE CONTACT

HYDROMORPHONE: Adult:

IV/IO/IM routes: 0.5 mg Dose may be repeated after 10 minutes and titrated to clinical effect up to maximumcumulative dose of 1.5 mg.Additional cumulative dosing requires BASE CONTACT.

Pediatric 1-12 years and 10kg: IV/IO/IM routes: 0.2 mg

Repeat dosing requires BASE CONTACT.

Pediatric < 1 years or < 10kg: IV/IO/IM routes: with verbal order only. BASE CONTACT for any administration

NOTE: IV route is preferred for all opioid administration because of more accurate titration and maximal clinical effect. IO/IM for all listed opioids and additionally IN for fentanyl are acceptable alternatives when IV access is not readily available. Repeat doses of IN Fentanyl can be given if IV access cannot be established. However greater volumes and repeat IN administration are associated with greater drug run off and may therefore be less effective. Continuous pulse oximetry monitoring is mandatory. Frequent evaluation of the patient’s vital signs is also indicated. Emergency resuscitation equipment and naloxone must be immediately available.

ProtocolExtremity Injuries Chest Pain Post Resuscitation Care with ROSC Abdominal Pain Amputations Burns Bites/Stings Snake Bites

Face and Neck Trauma Chest Trauma Abdominal Trauma Spinal Trauma

9240 MEDICATIONS

ORAL GLUCOSE (GLUTOSE, INSTA-GLUCOSE)

Description Glucose is the body's basic fuel and is required for cellular metabolism

Indications

Known or suspected hypoglycemia and able to take PO

Contraindications

Inability to swallow or protect airway

Unable to take PO meds for another reason

Administration All ages: One full tube 15 g buccal.

Protocol

Universal Altered Mental Status

Hypoglycemia


9250 MEDICATIONS


OXYGEN

Description Oxygen added to the inspired air increases the amount of oxygen in the blood, and thereby increases the amount delivered to the tissue. Tissue hypoxia causes cell damage and death. Conversely, hyperoxia has been linked with worsened outcomes in acute coronary syndromes and stroke. Therefore, oxygen should not be viewed as a harmless drug where more is better. EMS personnel should add additional oxygen when hypoxia, shock or respiratory distress are present titrating to a normal pulse oximetry reading above 90%.

Indications Hypoxemia or respiratory distressHypotension/shock statesSuspected carbon monoxide poisoningObstetrical complications, childbirthPre-intubation oxygenation

Precautions If the patient is not breathing adequately, the treatment of choice is assisted ventilation, not justoxygen.Do not withhold oxygen from any patient in respiratory distress, including COPD patients.

Administration

Use the appropriate oxygen delivery method and flow rate to achieve SpO2 of 90-96% whenoxygen therapy is indicated.

Special Notes Do not use permanently mounted humidifiers. If the patient warrants humidified oxygen, use asingle patient use device.Adequate oxygenation is assessed clinically and with the SpO2 while adequate ventilation isassessed clinically and with waveform capnography.

9260 MEDICATIONS

PHENYLEPHRINE (INTRANASAL)

Description

Phenylephrine is an alpha adrenergic agonist. When administered intranasally, it causesvasoconstriction in the nasal mucosa and subsequently decreased bleeding and nasaldecongestion.

Indications

Prior to nasotracheal intubation to induce vasoconstriction of the nasal mucosa

Nosebleed (epistaxis).

Precautions

Avoid administration into the eyes, which will dilate pupil.


Instill two drops of 1% solution, or 2 sprays, in the nostril prior to attempting nasotrachealintubation.

For patients with active nosebleed, first have patient blow nose to expel clots. Then, administer 2sprays into affected naris(es).

Protocol

Nasotracheal intubation

Epistaxis


9270 MEDICATIONS

RACEMIC EPINEPHRINE

Description Racemic epinephrine 2.25% is an aqueous solution that delivers 11.25 mg of racemic epinephrine per 0.5mL for use by inhalation only. Inhalation causes local effects on the upper airway as well as systemic effects from absorption. Vasoconstriction may reduce swelling in the upper airway, and ß effects on bronchial smooth muscle may relieve bronchospasm.

Onset & Duration

Onset: 1-5 minutes

Duration: 1-3 hours

Indications

Stridor at rest

Side Effects

Tachycardia

Palpitations

Muscle tremors

Dosage and Administration 0.5 ml racemic epinephrine (acceptable dose for all ages) mixed in 3 mL saline, via nebulizer at 6-8 LPM to create a fine mist and administer over 15 minutes.

Protocol

Pediatric Stridor/Croup


Racemic epi is heat and photo-sensitive

Once removed from the refrigerator, the unopened package is stable at room temperature untilthe expiration date stated on the package.

Do not confuse the side effects with respiratory failure or imminent respiratory arrest.

If no racemic epinephrine is available, consider 5 mL of 1:1,000 epinephrine x 1 via nebulizer at6-8 LPM to create a fine mist and administer over 15 minutes.


9280 MEDICATIONS

SODIUM BICARBONATE

Description Sodium bicarbonate is an alkalotic solution, which neutralizes acids found in the body. Acids are increased when body tissues become hypoxic due to cardiac or respiratory arrest.

Indications

• Tricyclic overdose with arrhythmias, widened QRS complex or hypotension.

• Suspected hyperkalemic pulseless arrest: consider in patients with known renal failure/dialysis.

• Crush injuries immediatley prior to release

Contraindications

Metabolic and respiratory alkalosis

Hypocalcemia

Hypokalemia

Adverse Reactions

Metabolic alkalosis

Paradoxical cerebral intracellular acidosis

Sodium bolus can lead to volume overload

Drug Interactions

May precipitate in calcium solutions.

Alkalization of urine may increase half-lives of certain drugs.

Vasopressors may be deactivated.

Dosage and Administration Adults and children (> 10 kg), 8.4% Tricyclic OD with hypotension or prolonged QRS > 0.10 sec or suspected hyperkalemia-related pulseless arrest:

1 mEq/kg slow IV push. Repeat if needed in 10 minutes.

Protocol

Universal Pulseless Arrest

Poisoning/Overdose


Sodium bicarbonate administration increases CO2 which rapidly enters cells, causing aparadoxical intracellular acidosis.

Sodium bicarb is no longer recommended for routine use in prolonged cardiac arrest. Its use inpulseless arrest should be limited to known or suspected hyperkalemia (e.g. dialysis patient), orarrest following tricyclic overdose.


Crush injuries 50 mEq IV/IO immediately prior to release

9290 MEDICATIONS

TOPICAL OPHTHALMIC ANESTHETICS

Description Proparacaine and tetracaine are local anesthetics approved for ocular administration for relief of eye pain caused by corneal abrasion or chemical injury.

Indications

Pain secondary to eye injuries and corneal abrasions.

Topical anesthetic to facilitate eye irrigation.

Contraindications

Known allergy to local anesthetics.

Globe lacerations or rupture.

Precautions

Transient burning/stinging when initially applied.


Instill 2 drops into affected eye. Contact Base for repeat dosing.


This is single patient use. Unused portions should be discarded and only new bottles may beused.

Do not administer until patient consents to transport and transport has begun.

Topical ophthalmic anesthetics should never be given to a patient for self-administration.


9300 MEDICATIONS

VASOPRESSOR CONTINUOUS INFUSION – ADULT PATIENTS ONLY

Description:

Epinephrine: Preferred vasopressor for all indications.

Endogenous catecholamine alpha, beta-1, and beta-2 adrenergic receptor agonist.Causes dose-related increase in heart rate, myocardial contractility and oxygen demand,peripheral vasoconstriction and bronchodilation

Dopamine: may be used as an alternative vasopressor for indications of hypotension or bradycardia, but not for anaphylaxis or status asthmaticus.

Endogenous catecholamine chemically related to epinephrine and norepinephrine.Increases blood pressure through combination of dopamine, alpha and beta receptoreffects leading to increased heart rate, contractility and peripheral vasoconstriction.

Indications:

Epinephrine:

Severe Allergic Reaction/Anaphylaxis

Hypotension with poor perfusion refractory to adequate fluid resuscitation (typically 30mL/kg crystalloid)

Bradycardia with signs of poor perfusion

Dopamine:

Hypotension with poor perfusion refractory to adequate fluid resuscitation (typically 30mL/kg crystalloid)

Bradycardia with signs of poor perfusion

Contraindications:

Do not use vasopressor infusion in PEDIATRIC patients (age less than 12 years)

Adverse Reactions

Dysrhythmia

Hypertension

Anxiety

Angina

Drug Interactions

Do not add to sodium bicarbonate or other alkaloids as epinephrine will be inactivated at higherpH.


9300 MEDICATIONS

Dosage and Administration:

Epinephrine:

Mix: inject 1 mg epinephrine into 1000 mL Normal Saline bag to achieve 1mcg/mL concentration(This means 1 mL of 1:1000 or 10 mL of 1:10,000 – either way 1 mg of drug). Use macro drip set.

Adult IV/IO: Begin IV/IO infusion wide open to gravity to give small aliquots of fluid. Typicalvolumes are less than 100 mL of total fluid, as typical doses are expected to be < 100 mcg.Titrate to desired hemodynamic effect with goal BP of > 90 mmHg systolic, improved respiratorystatus (bronchodilation), and improved perfusion/mentation.

Dopamine:

Mix: 400 mg in 250 ml NS or 800 mg in 500 ml NS to produce concentration of 1600 mcg/mL.

Adult IV/IO: 5-20 mcg/kg/min, Start at 5 mcg/kg/min, Titrate dose up 5 mcg/kg/min every 5 min toa max of 20 mcg/kg/min to desired hemodynamic effect.

Protocol

Post-Resuscitation Care with ROSC

Bradycardia with Poor Perfusion

Allergy and Anaphylaxis

Medical Hypotension/Shock

Overdose and Acute Poisoning


May increase myocardial oxygen demand and angina pectoris. Use with caution in patients withknown or suspected CAD


1 2

3

4

5

PIT CREW CPR (5 RESPONDERS)

POSITION 4

POSITION 1

-Initial Pt. assessment

-Move Pt. to workable area

-Perform uniterruptedcompressions for2 min

-Assist position 2while off compressions

POSITION 2

-Apply monitor pads

-Defibrillate

-Cycle with Position 1 every 2 min

-Place Lucas withPosition 1

-IV/IO acccess

-Administer medication

POSITION 5

-Team lead

-Timekeeping

2ND DUE

-Scribe/Timekeeper

-Scene Liaison

-Egress

POSITION 3

-Manage Airwaypassive oxygenation

-Prepare I-gel orintubation

6

7

8 9

ALS

BAG

LUCA

S

AIR

WAY

02

EGRESS

SCENE LIAISON

TIMEKEEPERSCRIBE

PLATTEVILLE GILCREST FIRE PROTECTION DISTRICT

INCIDENT #_____________

DOB:

Pulse: Respiration: SpO₂: _____________

Contact:

Transport: Activation: ED Arrival:

6. Patient does, or does not have an allergy to contrast dye…………………………………………………………………

***Cardiac Monitor Transmitted to Cardiac Catheterization Lab of Destination by Paramedic #_______***

5. Patient is currently on an anticoagulant (ex. Coumadin, Xarelto, Eliquis,Pradaxa)……………………………………………………………………………………………………………………………………………

4. Patient is 35-85 years old …………………….………………………………………………………………………………………

Information that MUST be communicated to ED physician and Cardiologist.

AND2. 1mm ST segment elevation is present in at least two (2) anatomically contiguous leads (Attach12 Lead)

All of the above criteria must be checked in order to activate a "Cardiac Alert" from the field!!

If unsure of cardiac alert, call and discuss with receiving facility.

3. No wide complex QRS (Paced Ryythm, LBBB, other)……………………………………………………………………..

1. Patient with active chest pain or discomfort, dyspnea or diaphoresis consistent with an acutecoronary syndrome (Less than 12 hours)...............................................................................................

Baseline Vitals BP:

Dispatch Time:

PCR#_____________

Patient Name

CARDIAC ALERT CHECKLIST


Platteville Gilcrest Fire Protection District

Stroke Alert Checklist

Patient Name: Date of Birth:

Information / History From: Phone:

Bring contact person to the hospital with patient if possible

Facial Droop: (Have Patient Smile) Abnormal

Normal: Both sides of face move equally

Abnormal: One side of the face does not move as well □

Arm Drift: (Have Patient Hold Arms Out For 10 Seconds)

Normal: Both arms move equally or not at all

Abnormal: One arm drifts compared to the other or not at all □

Speech: (Have Patient Speak a Simple Sentence)

Normal: Patient uses correct words with no slurring

Abnormal: Slurred or inappropriate words or mute □

Time: (Last Known Time Patient Was at Baseline or Deficit Free)

Less Than 7 Hours Time: Date: □

To activate a “Stroke Alert” from the field, at least one of the above neurological criteria AND time less than 12 hours must be checked!!

Patient Information Only: Yes No

1. Blood Glucose is between 50 mg / dL and 400 mg / dL: mg / dL □ □ 2. Hypertension: (Systolic is > 185. Diastolic is > 110): / □ □ 3. Seizure at onset of stroke: □ □ 4. Current use of anticoagulation (Coumadin , Pradaxa, Xarelto) □ □ 5. Neurosurgery (Head / Spine) or serious head trauma or stroke within last 3 months. □ □ 6. Major Surgery within the last 12 weeks. □ □


Platteville Gilcrest Fire Protection District Sepsis Alert Checklist

Patient Name___________________________________ DOB___________________

Date___________CR#______________________ PCR#_______________________

Are there two or more SIRS criteria? Evaluate potential SIRS Criteria:

____ Temp < 36C (96.8F) or > 38C (100.4F)

____ HR > 90 (or tachycardic for age)

____ RR > 20 or mechanical ventilation (or tachypneic for age)

____ Suspected or confirmed infection (recent antibiotic use)

Is there evidence of hypoperfusion? (Septic Shock) (ANY ONE OF THE FOLLOWING):

____ Hypotension for age

____ Altered mental status (excluding simple febrile seizure)

____ Delayed capillary refill AND mottling

____ Systolic BP < 90 mmHg

____ MAP <65

____ Sustained EtCO2 <25mmHg

Meets Sepsis Alert Check List YES NO

If Septic Shock Criteria IV fluid bolus @ 30mL/kg (if no sign of fluid overload) establish 2 large bore IV’s Transport to closest appropriate hospital

For ongoing hypotension, poor perfusion or pulmonary edema, consider Vasopressor Infusion (adult patients only)

Paramedic________________________________

Appendix D – EMS Response, Treatment, Transport, and

Delivery to Hospital of Highly Infectious Patients

Purpose

Provide guidance to protect the health and safety of EMS and first responders while providing appropriate medical treatment for patients with suspected or confirmed Ebola or other highly infectious diseases including transport to an appropriate medical facility for assessment and medical treatment.

Goal

To develop a general guideline for EMS response to a patient under investigation (PUI)/confirmed Ebola or highly infectious disease patient during a(n):

• 9-1-1 request for service with signs or symptoms of Ebola

• Local Public Health Agency (LPHA)request for PUI/confirmed Ebola patient transport

• Interfacility transport request for PUI/confirmed Ebola patient

Partners

On all PUI or confirmed Ebola or other highly infectious disease cases EMS works in partnership with the following agencies:

• CDPHEo Disease Control and Environmental Epidemiology Division (DCEED)o Health Facilities and EMS Division (HFEMSD)o Office of Emergency Preparedness and Response (OEPR)o Local Public Health Agencies (LPHA)o State-agreed Ebola EMS transport agencies

PGFPD should collaborate with Weld County Public Health, emergency management and health care coalition to develop response and transport plans according to current CDC guidelines http://www.cdc.gov/vhf/ebola/healthcare-us/emergency-services/ems-systems.html for PUI/confirmed Ebola patients.

Plan

Ebola and other highly infectious diseases pose a high risk to public health and can place EMS providers at risk for exposure especially during the late stages of the disease. To limit the possibility of Ebola transmission, it is important that any agency responding to, treating, or transporting a suspected or confirmed Ebola patient develop specific Ebola policies, procedures, protocols, and actively train to maintain proficiency. Responding to and transporting a suspected or confirmed Ebola patient is labor and equipment intensive and should only be performed by qualified and trained responders. If a 9-1-1 response indicates a potential highly infectious disease patient and PGFPD is unable to appropriately care for or transport the patient and provide proper PPE http://www.cdc.gov/vhf/ebola/healthcare-us/ppe/guidance.html and resources for the EMS crew, PGFPD should request state-agreed EMS assets through the CDPHE.

http://www.cdc.gov/vhf/ebola/healthcare-us/emergency-services/ems-systems.html


http://www.cdc.gov/vhf/ebola/healthcare-us/ppe/guidance.html


9-1-1 Response

Despite diligent monitoring by the LPHA, CDPHE, and CDC, a person who has had contact with a highly infectious and traveled to the United States might circumvent the screening system and end up dialing 9-1-1 once ill. It is important that all Public Safety Answering Points (PSAPs) along with EMS agencies properly screen callers and patients with recent travel to a country currently being monitored for Ebola or other highly infectious disease who exhibit one or more of the following signs and symptoms:

• Fever

• Severe headache

• Muscle pain

• Vomiting

• Diarrhea

• Abdominal pain

• Unexplained hemorrhage

Note: Not all monitored travelers who access 9-1-1 for an emergency should be considered suspected of having Ebola if the complaint is not consistent with Ebola or other highly infectious disease signs and symptoms.

It is crucial that EMS responding crews practice scene safety, scene size-up, and proper use of PPE http://www.cdc.gov/vhf/ebola/healthcare-us/ppe/guidance.html on all responses. If an EMS crew encounters a situation where signs and symptoms indicate potential Ebola or other highly infectious disease and a patient has traveled from a country with widespread transmission of the disease or has had contact with an infectious disease patient within 21 days of experiencing symptoms:

• Maintain a safe distance until proper PPE is donned- (at least three feet)http://www.cdc.gov/vhf/ebola/healthcare-us/ppe/guidance.html

• Provide appropriate medical treatment for the patient consistent with patient presentation

• Contact EMS Chief to determine plan - ready appropriate vehicle or transfer care to oneof the state-agreed EMS Ebola/highly infectious disease transport agencies

• Contact CDPHE to collaborate on appropriate care and determine patient disposition303-692-2700 during working hours

or Afterhours 303-370-9395

• Transport the patient to the most appropriate facility according to CDC guidelineshttp://www.cdc.gov/vhf/ebola/healthcare-us/emergency-services/ems-systems.html

Public Safety Answering Points

Public Safety Answering Points (PSAP) are the cornerstone of public protection when 9-1-1 is activated. The safety of the EMS providers responding to an emergency call depends on information provided by the PSAP dispatcher. PSAPs should follow the CDC Guidelines http://www.cdc.gov/vhf/ebola/healthcare-us/emergency-services/ems-systems.html for DISPATCH/9-1-1 PSAPS which include asking about recent travel to an Ebola monitored country.









Considerations in developing local EMS response for calls received through a PSAP:

• Has the PSAP for the EMS agency implemented the CDC guidelineshttp://www.cdc.gov/vhf/ebola/healthcare-us/emergency-services/ems-systems.htmlregarding Ebola?

• Is the PSAP screening for symptoms and travel?

• Is the PSAP relaying pertinent call information to the responders?

• Is there a secure communication mode in place for dispatching a potential Ebolaresponse?

• Are there confidential radio codes in place that only the PSAP and agencies know torefer to an Ebola or other highly infectious disease patient and response to preventunintentional media release?

• Does the PSAP have a protocol in place to contact the local public health agency, EMSagency management, the appropriate response unit and other essential agencypersonnel necessary for an Ebola or other highly infectious disease response?

Response

• If contacted by Weld County Public Health for a PUI, non-emergent response isrecommended.

• If unknown, respond per discretion of dispatch or BC

• Contact EMS Chief for possible response and/or coordination with Weld County PublicHealth /CDPHE

Treatment

Due to the highly infectious properties of Ebola and other highly infectious diseases, EMS treatment should be limited to only necessary care depending upon the situation, per CDC Guidelines (Interim Guidance for Emergency Medical Services (EMS) Systems and 9-1-1 Public Safety Answering Points (PSAPs) for Management of Patients Under Investigation (PUIs) for Ebola Virus Disease (EVD) in the United States and medical direction http://www.cdc.gov/vhf/ebola/healthcare-us/emergency-services/ems-systems.html.

• If PPE has not been donned prior to patient contact, maintain at least a three-foot bufferbetween the EMS provider and the patient.

• Ensure all EMS providers have appropriate PPE donned if they will have any patientcontact which includes moving the patient to and from the gurney.

• IV insertion only if patient condition requires it for specific treatment

• Base Contact suggested for specified treatment based on patient conditiono Antiemetico Benzo for anxietyo Pain Managemento Other supportive care required





Transport

Ebola or other highly infectious disease patients late in the disease stage can lose a significant amount of fluids both orally and rectally. EMS crews should avoid performing unnecessary interventions during transport to reduce the potential risk of Ebola transmission.

• Properly wrap the patient compartment area with the decon tarps

• Notify Weld County Public Health/CDPHE early in the response to determine the mostappropriate facility- Most likely transport facility will be either Denver Health or UC HealthAurora (AIP)

• Consider requesting Banner Health or Denver Health for transport if staffing and vehiclesare limited

• DO NOT call for helicopter transport

• Provide only supportive measures- suction, antiemetic, sedation/pain control- DO NOTuse needles or attempt intubation while actively moving

• Base Contact for life saving measures

Delivery to hospital and decontamination

During any response and transport of a PUI or confirmed Ebola patient, EMS agencies must work in collaboration with the Weld County Public Health and CDPHE to determine the proper receiving facility for the patient. Considerations when delivering an Ebola or other highly infectious disease patient:

Once the patient is transferred to the facility, EMS will need to properly:

• Doff PPE according to CDC guidelines http://www.cdc.gov/vhf/ebola/healthcare-us/ppe/guidance.html in a designated doffing location

• Decontaminate the ambulance and gurney according to CDC guidelineshttp://www.cdc.gov/vhf/ebola/healthcare-us/emergency-services/ems-systems.html

• Determine steps for crew monitoring if needed- consult LPHA

LPHA Request for EMS Transport of Monitored Patient

If a person being monitored by a LPHA starts showing signs and symptoms of illness, the LPHA will call CDPHE to discuss the situation as described in the Traveler Monitoring Protocol. The protocol “Disease Control Steps for Responding to a Person under Investigation (PUI) for Ebola” details the steps public health will follow to respond to a PUI. If it is determined that a PUI needs to be transported by EMS, public health will consider the following, relying on the LPHA to provide information about local EMS systems:

• Can local EMS safely handle the response and transport?

• Does the local EMS agency have proper PPE http://www.cdc.gov/vhf/ebola/healthcare-us/ppe/guidance.html for an Ebola patient, trained on donning and doffing of PPE andhave adequate personnel and vehicles to perform the transport?











• Is it more appropriate to use a state-agreed asset to provide the response or transport?

If the local EMS agency is not able to handle the transport, the LPHA will contact CDPHE to arrange for state-agreed EMS assets to provide response and transport consistent with the Emergency Medical Services Ebola Communication Plan. If the local EMS agency is able to handle the suspected or confirmed Ebola patient, the state-agreed EMS transport agencies should be contacted to provide technical assistance to the local EMS agency. LPHAs have plans in place that take into consideration local factors for EMS transport. These plans should be made in advance of responding to a PUI.

Response, transport and delivery to a designated ETC or EAH should follow the considerations found in the above Safety, Treatment, Transport and Delivery to Hospital and Decontamination sections.

Interfacility Transport Request

If a PUI or confirmed Ebola patient needs to be transported from a medical facility to an ETC or EAH, the facility will contact the LPHA and CDPHE to arrange for state-agreed EMS assets to provide response and transport consistent with the Emergency Medical Services Ebola Communication Plan Appendix G.3

Response, transport and delivery to a designated ETC or EAH should follow the considerations found in the above Safety, Treatment, Transport and Delivery to Hospital and Decontamination sections.


The following is a list of approved medical abbreviations. In general, the use of abbreviations should be limited to this list.

A&O x0-4 → Alert and Oriented

ABC → Airway, Breathing, Circulation

abd → abdomen

A-Fib → atrial fibrillation

AKA → above knee amputation

AAA → abdominal aortic aneurysm

AC → antecubital

ACLS → Advanced Cardiac Life Support

AED → Automated External Defibrillator

ALS → Advanced Life Support

aloc → altered level of consciousness

AMA → against medical advice

AMI → Acute Myocardial Infarction

AMS → altered mental status

ASA → acetyl salicylic acid (Aspirin)

BBB → Bundle Branch Block

BBS → bilateral breath sounds

BGL / BG → blood glucose

BKA → below knee amputation

BLS → Basic Life Support

BP → blood pressure

BS → breath sounds

BVM → Bag Valve Mask

C/O → complaining of

CA → Cancer

CABG → Coronary Artery Bypass Graft

CAD → Coronary Artery Disease

C/C → Chief Complaint

CHF → Congestive Heart Failure

CNS → central nervous system

CO → Carbon Monoxide

COPD → Chronic Obstructive Pulmonary Disease

CP → Chest Pain

CPR → Cardiopulmonary Resuscitation

CSF → cerebrospinal fluid

CTL → cervical, thoracic, lumbar

CVA → Cerebral Vascular Accident

D5W → 5% Dextrose in water

D10 → 10% Dextrose

D50 → 50% Dextrose

DKA → diabetic ketoacidosis

DNR → Do Not Resuscitate

DOA → Dead on Arrival

DT → Delirium Tremens

DVT → deep vein thrombosis

ECG → Electrocardiogram

ED / ER → Emergency Department

EJ → external jugular

EKG → Electrocardiogram

EPI → Epinephrine

ETT → Endotracheal Tube

ETOH → ethyl alcohol

Fx → fracture

g → gauge

GCS → Glasgow Coma Scale

GI → gastrointestinal

GSW → gunshot wound

gtts → drops

GYN → gynecology (gynecological)

Hg → Mercury

HPI → history of present illness

HR → Heart Rate

HTN → hypertension

Hx → history

ICP → intracranial pressure

IM → intramuscular

IO → Intraosseous

IV → intravenous

JVD → jugular vein distention

kg → kilogram

K → Potassium

KVO → Keep Vein Open

Lb / lbs → pound(s)

LLQ → left lower quadrant

LMP → last menstrual period

LPM → liters per minute

LOC → level of consciousness

LR → lactated ringers

LS → lung sounds

LUQ → left upper quadrant

LVH → Left Ventricular Hypertrophy

MAE → moves all extremities

MAP → mean arterial pressure

mg → milligram(s)

mcg → microgram

MCI → mass casualty incident

MDI → metered dose inhaler

mEq → milliequivalent

MI → Myocardial Infarction

mL → milliliter

mmHg → millimeters of mercury

MVA / MVC → motor vehicle accident

NC → Nasal Cannula

Neb → Nebulizer

NG → nasogastric

NKA → No Known Allergies

NKDA → No Known Drug Allergies

NPA → nasopharyngeal airway

NRB → non-rebreather mask

NS / NSS → normal saline

NSR → normal sinus rhythm

NT → non-tender

NTG → Nitroglycerine

N/V → nausea/vomiting

N/V/D → nausea/vomiting/diarrhea

O2 → Oxygen

OB / OBGYN → obstetrics/gynecology

OPA → oropharyngeal airway

P → Pulse

PAC → Premature Atrial Contractions

PALP → palpation

PALS → Pediatric Advanced Life Support

PCN → Penicillin

PE → Pulmonary Edema or Pulmonary Embolism

PEA → Pulseless Electrical Activity

PEEP → positive end-expiratory pressure

PERRL → pupils equal, round, and reactive to light

PMHX → past medical history

PO → by mouth

POV → privately owned vehicle

PSVT → paroxysmal supraventricular tachycardia

Pt → patient

PTA → prior to arrival

PRN → as needed

PVC → Premature Ventricular Contraction

RLQ → right lower quadrant

ROSC → return of spontaneous circulation

RR → respiratory rate

RUQ → right upper quadrant

SaO2 → systemic arterial oxygen saturation

SpO2 → oxygen saturation by pulse oximeter

SpCO → carbon monoxide saturation by pulse oximeter

SL NTG → sublingual Nitroglycerin

SNF → skilled nursing facility

SNT → soft non-tender

SOB → shortness of breath

SQ → Subcutaneous

SR → Sinus Rhythm

STEMI → ST elevated myocardial infarction

ST → Sinus Tachycardia

SVT → Supraventricular Tachycardia

SZ → Seizure

TCP → transcutaneous pacing

TIA → Transient Ischemic Attack

TKO → to keep open

Tx → treatment, transport

URI - upper respiratory infection

UTI → Urinary Tract Infection

V-fib / VF → Ventricular Fibrillation

VS → vital signs

V-tach / VT → Ventricular Tachycardia

Yo / y/o / YOA → years old (years of age)

M → Male

F→ Female

+ → positive

- → negative

= → equal

< → less than

> → greater than

L → left

R → right

medical protocols, procedures and treatment guidelines

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